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REPORT ON EABCT CONFERENCE 2023 1

By Maria Bekendam & Mieke Ketelaars

REPORT ON EABCT CONFERENCE 2023 By Maria Bekendam & Mieke Ketelaars

Published by VGCt December 2023 Design: kalterontwerpen.nl Cover illustration: Shutterstock

Table of contents Preface 7 PART I | INTERVIEWS WITH KEYNOTE SPEAKERS

Adam Radomsky

Fredrike Bannink

Keith Dobson

Kim Penberthy

Steffen Moritz

Simon Blackwell

Niklas Törneke

PART II | SUMMARIES OF SYMPOSIA

Cultural adaptation of psychological interventions

Metacognitive training for psychosis

The stigma of mental disorders

Body Dysmorphic Disorder in youth; what works and what doesn’t

The intergenerational transmission of mental illness: intervening interventions

Digital interventions; what should we keep in mind?

Preface In October 2023, the scientific team of the Dutch Association for Behavioural and Cognitive Therapies (VGCt) attended the EABCT conference in Antalya, Turkey. What are the latest research results and how can we translate them to clinical practice? In the first part of this report, we asked keynote speakers about their field of expertise. The second part consists of a summary of several keynotes and symposia.

Mieke Ketelaars has been working as a science journalist at the VGCt since 2019. Her activities include the development of products such as factsheets, podcasts and interviews. After studying Child and Adolescent psychology at Leiden University in the Netherlands, Mieke obtained her PhD at Radboud University Nijmegen. During that time she also worked as a psychologist. After several years as a university lecturer and program manager, Mieke became increasingly involved in translating scientific knowledge to a wider audience.

Maria Bekendam has been working as a science journalist at the VGCt since early 2022. She studied Positive psychology at the University of Twente in the Netherlands and she obtained her PhD at Tilburg University on the impact of psychological factors in patients with heart disease. After her research work, she was involved in edu cation and student counseling as a university lecturer. Through expert interviews and the development of factsheets and infograph ics, she aims to bridge the gap between scientific insights and clini cal practice.

PART I 8

INTERVIEWS WITH KEYNOTE SPEAKERS

Adam Radomsky Adam Scott Radomsky is a Canadian psychologist who studies obsessive-compulsive disorder (OCD) and related anxiety disorders. He is a professor in the Department of Psychology at Concordia University in Montreal, Canada, and was editorin-chief of the Journal of Behavior Therapy and Experimental Psychiatry.

You recently authored a paper on the fear of losing control in social anxiety disorder. In it, you conclude that beliefs about losing control may actually play a causal role in the development and maintenance of social anxiety disorder (SAD). How does this believe evolve? People can come to believe things in numerous different ways. I suspect that one possible pathway within the context of social anxiety disorder could be that following a social interac tion, someone might reflect on what took place (either briefly or more ruminatively) and per haps conclude or misinterpret their past social performance as having been ‘out of control’ or perhaps that they were not in control as a result of a perceived social mistake (e.g., trip ping over words, excessive sweating, too loud, inadequate answer/response, etc.). They may then come to believe that they are at increased risk of losing control in the future. How could CBT target this belief? There are numerous potential ways we could target beliefs about losing control. Psycho education and guided discovery strategies in which definitions of actual losses of control are discussed could be helpful. Perhaps more helpful would be behavioral experiments in which people are asked to try to lose control, or to make mistakes and then seek feedback from others. Further, investigating what it means to make a mistake or to make a bad decision, as distinct from losing control, could also be useful. Finally, a discussion of what we can control (e.g., behaviour) and can’t control (e.g., emotions, physiology) also has great potential in the clinic. Should we consider fear of losing control as a transdiagnostic symptom? I suspect it is. Anecdotally, it features in panic disorder, social anxiety disorder, obses sive-compulsive disorder, posttraumatic stress disorder, eating disorders, and other prob lems. The best answer to this question though, is that it is an empirical question. Fears and beliefs about losing control should be assessed in association with different problems; that will provide the best indicator of their transdiagnostic nature and potential. Prevention and early detection are becoming increasingly important in (mental) healthcare. Can you give some examples of recent developments in the prevention area of psychological healthcare? In what ways can prevention and early detection be improved in your field of expertise? Indeed, prevention and early detection are important. The challenges associated with pre vention strategies is that, as in therapy, we’re hoping that people will remember the valuable

prevention strategies and information given to them during times when anxiety and related disorders may emerge. That is a major challenge indeed! Early detection may be more suc cessful since regular screening of beliefs and behaviour that may put people at risk could serve to identify those most in need of intervention. But this too is an empirical question, and hopefully can be addressed both in the laboratory and the clinic.

Fredrike Bannink Fredrike Bannink is a clinical psychologist, child psychologist and lawyer. She is a trainer and supervisor of the Dutch Association for Behavioral and Cognitive Therapies (VGCt) and cofounder and past chair of the Positive CBT section. She is also founder and chair of the Special Interest Group of the European Association for Behavioral and Cognitive Therapies (EABCT). Fredrike is an international keynote speaker, trainer and author of about fifty books. 11

Positive CBT has been gaining momentum in recent years. Clients seem to be enthusiastic about it. Can you elaborate on some of the factors that contribute to this popularity among clients? In today’s challenging world there is a great need for positivity. Positive CBT uses a positive focus in all aspects of therapy. It integrates positive psychology and solution-focused brief therapy within a CBT framework. Instead of reducing distress and repairing the worst, as in traditional CBT, positive CBT focuses on building success and on creating the best. It changes what we focus on and how we work in helping people change. Describing the preferred future, finding exceptions to problems, discovering personal strengths and what works all help in achieving new and better lives for our clients. Therapy becomes more lighthearted, more positive and there is less burnout amongst professionals when using a positive focus. No wonder research also showed that clients prefer positive CBT over traditional CBT. Also, there is significantly less drop-out. There is a good amount of research showing that optimism can prevent depression. More recent research suggests optimism is a protective factor for cardiovascular diseases. What are the latest insights on the protective qualities of optimism for other somatic diseases? And more importantly, can optimism be trained/learned? Seligman, co-founder of the scientific positive psychology movement, shifted his attention from learned helplessness to learned optimism. He conducted research on the factors that lead people to perceive an event as positive or negative and their reasoning behind it. Pessimistic people attribute negative events to stable, global and internal factors, and posi tive events to temporary, specific and external factors. Optimistic people think in the oppo site way. In recent years, research has been conducted on the benefits of optimism for physical and mental health. There is a link between optimism and better physical health and psychological well-being. Optimistic people are more resilient in stressful situations and have a lower risk of developing psychological problems such as depression. In my book 201 Positive Psychology Applications (Norton, New York, 2017) you can find practi cal applications on how to improve optimism. Positive CBT shows how clients may (re)dis cover optimism. One client said: “I used to be a complete pessimist….this was a shock therapy for me. In the end I realized there were so many positive things which I had never perceived before. Now I am completely convinced: I choose to embrace the radical perspec tive of looking at things in a positive light”.

Can you elaborate on the ‘paradigm of synthesis’ and why it is such a paramount concept in positive CBT? In the philosophy of science we discern two ways of making the world understandable: the analysis paradigm and the synthesis paradigm. Traditional psychotherapy (also traditional CBT) uses the analysis paradigm: the medical model. It is a process of reducing a complex whole, or system, into its component parts and dealing with those parts in isolation. The medical model is rather straightforward: identify the (cause of the) problem and remove it. However, the medical model is often not sufficient when it comes to complex and rapidly changing problems. So in addition to the analysis paradigm there is the synthesis paradigm. We set out to design something, there is an output, something to achieve. It is not just a mat ter of removing a problem: there is a designed entity that was not there before. The synthe sis paradigm is based on putting things together. Sometimes these pieces are already known to be part of a system. In other cases, the combination of things never before thought of as going together create new concepts, solutions or realities. The Danish philosopher Kierkegaard stated: “Life can only be understood backwards, but it must be lived forwards”. Positive CBT works from the synthesis paradigm: for the first time CBT is future-focused: it focuses on the best possible outcome for our clients. About what they would like to have instead of their problems: their preferred future. That is why positive CBT is called ‘Fourth Wave CBT’. Prevention and early detection are becoming increasingly important in (mental) healthcare. Can you give some examples of recent developments in the prevention area of psychological healthcare? In what ways can prevention and early detection be improved in your field of expertise? In my book Practicing Positive Psychiatry (Bannink & Peeters, 2021) we state that traditional forms of psychiatry focus on diagnostics and therapeutics rather than on prevention of men tal illness. However, the mission of medicine is not only to treat diseases, but also to help patients live their lives in a positive way. This may have a great impact, not just on psychiat ric but also on overall medical education, leading toward a new medical model. Therapy should not be based on the question ‘What is the matter with you?’, but on the question ‘What matters to you?’. Prevention should be an important focus across the whole life span. In traditional psychiatry so far prevention is largely ignored. Positive psychiatry, however, is concerned with preven tive measures; not only to treat individuals but also to enhance the health of communi ties. This is particularly useful in secondary and tertiary prevention, where interventions to prevent deterioration of the patients’ situation or to remain stable after recovery (a recov ery-oriented approach) are applied. This concerns the reduction of vulnerability on the one hand, but also the enhancement of resilience and the ability to recover on the other.

Keith Dobson Keith Stephen Dobson is a clinical psychologist, academic and researcher. He is a professor of Clinical Psychology at the University of Calgary in Canada and also served as Head of the Psychology Department and Director of the Clinical Psychology program at the university. He is President of the World Confederation of Cognitive and Behavioral Therapies.

Based on your vast research efforts over the last decades, can you give your viewpoint on two broad questions regarding CBT for depression: what is its current status (recent developments, for example) and where is it heading to? With regard to the first part of the question, I will simply state that CBT for depression is a well-validated treatment in many countries and cultures, and across the range of different severities and symptom patterns that are experienced within the diagnosis of clinical depres sion. Outcomes generally suggest about a 10-20% dropout rate, and about a 60-70% success rate (defined as the end of the diagnosis) in treating patients who continue with treatment. These percentages suggest that overall we can successfully treat approximately 40-50% of the people who begin CBT for depression. These outcomes have been stable in recent years, but do not appear to be getting better. Our outcomes with CBT for depression are roughly comparable to different evidence- based treatments (e.g., interpersonal psychotherapy, problem solving therapy, behavioral activation therapy), and comparable to pharmaco therapy in the short term but somewhat stronger in the long term. There is some evidence that for more severe depression the combination of CBT and pharmacotherapy maybe the better strategy to achieve positive depression outcomes. It appears that the field is interested in continuing to conduct CBT trials, more or less as a standard treatment package. Recent studies have focused on depression in specific popula tions (e.g., in cancer care, people with comorbid conditions, patients who have not responded to other forms of treatment), and while this research certainly helps to under stand the generalizability of CBT for depression, it does not in general lead to improved out comes or our better understanding of the mechanisms of action. My own concern is that we are also not integrating knowledge about risk factors for depression into our ongoing treat ment models. For example, there is now extensive evidence that diet, exercise and sleep are all relatively important factors in many cases of depression. Further, there are effective inter ventions that could be offered to address these issues in conjunction with CBT, to enhance outcome. I am also increasingly of the opinion that as therapists we need to be more selec tive in the interventions we are considering. While for example one client may be success fully treated with primarily behavioral activation interventions, and another client may require problem solving for truly difficult life circumstances, yet another may need extensive cognitive training and skills development. Put differently, we need to have ideographic assessment and intervention plans in order to choose the interventions that best meet the client’s needs.

What do you think about upcoming other forms than ‘traditional’ CBT, such as positive CBT for treating depression? I think that whenever we have an evidence-based intervention, it should become part of the total pool of interventions that should be considered for a given client. In practice, it often makes sense to sequence treatments, beginning with more fundamental skills such as behavioral activation (including attention to exercise and sleep), moving to problem solving and cognitive restructuring interventions, and only later in the course of therapy directly addressing core beliefs or schemas that may be important in the client’s life. Throughout treatment, one must of course always attend to the treatment goals and in doing so we must also understand the values and culture of the client, so that our interventions optimally sup port their personal long-term goals. 14

You asked specifically about the integration of positive CBT into the treatment of depression. Although I do think that this integration has a role in some cases, most clients entering treat ment for depression want to reduce or remediate negative symptoms. As such, a focus on positive CBT too early in the course of therapy will not match their treatment goals. In con trast, once the client begins to improve and feel better about himself and his life course, then integrating positive CBT elements into treatment makes perfect sense. I would similarly suggest that mindfulness as an intervention for depression can be effective, but typically less so in the early phases of treatment of depression. Indeed, the literature suggests that mind fulness-based cognitive therapy or MBCT can be an effective relapse prevention strategy, but perhaps not an effective treatment for acute phases of depression. These comments are par ticularly the case for more severe depression, because there the focus likely needs to remain on solving current problems and symptoms for a longer period of time. Sometimes a therapist finds himself ‘stuck in a loop’ with a patient and unable to move towards mutually agreed treatment goals. What are some strategies for therapists working with depressed patients to maximize treatment success? As with so many issues, it is typically better to prevent these issues from the beginning, than treating them once they exist. Some strategies to reduce the likelihood of getting stuck include having clear and measurable outcome goals, developing a consensual set of treat ment goals, respecting the client’s desires and typically beginning to work on those goals that the client sees as the most important ones (this strategy also helps to build client engagement in therapy), developing a positive therapeutic relationship, and ensuring that both you and the client measure and review success, for example in homework assignments. Some clients with depression feel helpless and may solicit stronger support from you as therapist than other clients. If you feel this pull, it is important to not work too hard, to not over-congratulate him for homework well done, and generally to not immerge yourself into the client’s life more than is necessary. I will give one example, which often happens with homework assignments. Many clients with depression will anticipate that homework assign ments are going to be difficult, and possibly overwhelming. Therapists in such a situation may feel the desire to encourage the client and tell them that they have more ability than they think they do. Similarly, many clients with depression who have completed a home work assignment, will return to therapy and say that it was easier than anticipated and that ‘anyone’ could have done it. In response, the therapist may feel the urge to congratulate the

client and give him praise for the assignment. However, in both instances the therapist’s response undermines the client’s ability to work on challenging issues. And also: the client’s ability to give himself appropriate appraisal and credit for the work that he has done. In gen eral, my position is that if you as therapist find yourself working too hard or being ‘stuck’, you need to recognize this process, disengage from your effort to help the client, and move (back) towards a more shared responsibility for care. If you are measuring outcomes with a standardized depression scale (as everyone should) you and the client can look together at the response or non-response to treatment, and potentially redesign the interventions that you are using to get back on track. It is also important to recognize that even the best thera peutic effort may not always lead to successful outcome. At some point it may become nec essary to consider referral to an alternative form of intervention. 15

Prevention and early detection are becoming increasingly important in (mental) healthcare. Can you give some examples of recent developments in the prevention area of psychological healthcare? In what ways can prevention and early detection be improved in your field of expertise? It is natural that healthcare systems focus on individuals who already have a given diagnosa ble condition, and to try to develop effective treatment systems. Unfortunately, this health care model requires that people must suffer before (hopefully) achieving recovery. We know now, however, that there are many risk factors for depression that can be affectively medi ated before a person develops depression. For example, adverse childhood experiences are now clearly associated with increased risk for later depression, and interventions for chil dren who experience adversity are likely cost-effective strategies to reduce later burden healthcare for depression. Parental depression, and in particular maternal depression, is also a risk factor for depression in the offspring. Recognizing the effects that parents may have on their children and treating parental depression can therefore be an effective strategy to prevent depression in their children. There is ample evidence that one of the early warn ing signs for depression is sleep disturbance, and so addressing some of those ‘prodromal’ signs of depression (ideally, without medication) can significantly reduce the frequency of later onset. One of the great learnings from the recent Covid pandemic is the critical impor tance of social connection and support to reduce the likelihood of future depression. So again, helping people to develop optimal social skills and social connection (which varies from person to person) is an effective strategy to decrease the future risk of depression. In short, there are now a number of known risk indicators that have evidence-based interven tion strategies which can be deployed as considered appropriate. A very good forthcoming reference on this topic, if I do say so myself, is a book by David Dozois and myself (APA, spring 2024), as it directly targets effective interventions for risk indicators. The challenge is how to provide interventions to people who may not yet be experiencing signs or symptoms of depression, or related mental health challenges. Population-based interventions typically have a modest effect size, and they are not terribly cost effective. In contrast, selective and indicated prevention strategies (either for people who have the risk indicators, or are showing the early signs of depression, respectively) both appear to be cost effective and reduce onset for depression and. Indicated prevention strategies in particular require early detection strategies. Some countries have tried to institute a national depres sion screening day to institute early detection, and this is not a bad idea. Training family

physicians and walk-in clinics to also be able to conduct screening is a useful strategy (if the screening is actually conducted). Generally, having an increased awareness of the signs and symptoms of depression in society and encouraging people to step forward for a compre hensive assessment when indicated is recommended. The onus then is on the healthcare system to provide appropriate indicated treatments. Unfortunately, Western healthcare sys tems often lack actual matching interventions in the prevention phase.

The other aspect of depression prevention that needs to be developed is within the preven tion of relapse or recurrence. We know that many people who experience a single episode of depression, even if it has been treated successfully, are at increased risk of relapse or recur rence. Sometimes, this increased risk is related to residual signs and symptoms of depres sion that are not fully treated in the first instance. In other cases, the risk factors associated with the initial episode of depression remain and have not been adequately addressed in treatment. In yet other cases, new circumstances may develop that more easily lead the indi vidual back into a course of depression. Although optimal models for relapse prevention are still being developed and evaluated, at the very least we know that individuals who have been depressed and treated need to continue to monitor their symptomatology for a long period of time, and return to care as quickly as possible if a subsequent episodeappears to be developing. Conclusions In short, we know much more about depression that we did some twenty years ago and that knowledge can be successfully used in our screening, assessment, and treatment programs. CBT remains a vital part of the healthcare options to help people who are struggling with depression. At the same time, the number of interventions with an evidence base has grown, and single model interventions (including CBT) are likely going to be of less value as the field develops. My own belief is that a more expanded and integrative model of treatment for depression, based on CBT but incorporating a broader biopsychosocial framework, is likely to increase our success rates with depressed clients, and provide a better match of interven tions with the needs of the clients. This type of expanded model needs considerable atten tion and evaluation, but I do think it can be the pathway towards better treatment programs for clients with depression.

Kim Penberthy Kim Penberthy holds the Chester F. Carlson Professorship Chair in Psychiatry & Neurobehavioral Sciences at the UVA School of Medicine. She is a clinician, researcher, teacher and innovator using contemplative practices to help people with mental suffering, addiction, and chronic medical conditions, such as cancer and lupus. She also employs mindfulness and contemplative practices to help educate medical residents and physicians in how to work best with distressed patients while also taking care of themselves. 17

You recently published an article about After Death Communications. Can you elaborate on this subject and why it is relevant for people’s lives and well-being? Perceived After Death Communications (ADCs) can significantly impact people’s lives and well-being by providing comfort and solace to those grieving, potentially easing the pain of loss. Having ADCs is very common in every culture. Most people find that experiencing per ceived communications from deceased loved ones helps them in the grieving process, by fostering a sense of continued connection and offering reassurance of their loved ones’ well-being. These experiences can help in diminishing the fear of death, instilling hope, and alleviating the sorrow associated with the separation of death. Our research shows a sub stantial role of ADCs in grief and healing that suggests the need for additional research. You investigated the effectiveness of online mindfulness and Acceptance and Commitment Therapy (ACT) interventions, for example for smoking cessation, and found that most of these interventions were not effective for abstinence rates. How do you explain these findings? Do you still believe in online or remote interventions considering these results? Our recent systematic review investigated the effectiveness of remotely delivered mindful ness and ACT for smoking cessation. Fifteen studies were evaluated: five using mindfulness and ten using ACT. The majority showed no significant difference in abstinence rates between intervention and control groups, with only two ACT-based interventions indicating a significant difference at follow-up. Issues in design, follow-up, and technology may explain the lack of significant results. ACT-based interventions were generally more robust. The review concludes that the effectiveness of remote interventions for smoking cessation needs further study due to predominantly inconclusive findings. These findings do not negate the impact of online or remote interventions but indicate that some disorders may be better treated in person. As for the treatment of depressive disorders, what do you think are promising treatment methods for the years to come? The future of treating depressive disorders looks promising, with advancements focusing on individualized and holistic approaches. Rapid-acting antidepressants like ketamine and its derivatives show high efficacy. Psilocybin therapy is revealing breakthrough benefits. Enhanced SSRIs are under development, offering improved symptom relief. Neuromodulation techniques like TMS and tDCS present non-invasive treatment methods.

Digital mental health interventions, leveraging AI and VR, offer accessible support and per sonalized treatment. Advances in genetic and neuroimaging research facilitate more accu rate diagnoses and targeted treatments. Integrating lifestyle changes, nutrition, exercise and mindfulness form a holistic approach, addressing underlying causes and promoting mental well-being.

Steffen Moritz Steffen Moritz is Head of the Clinical Neuropsychology Working Group of the Department of Psychiatry and Psychotherapy at the University of Hamburg-Eppendorf Medical Center in Germany. His major research areas are metacognitive interventions, cognitive biases, information processing in schizophrenia, OCD, depression and PTSD. He is also an instructor in the Metacognitive Education program.

What are the most common cognitive distortions in psychosis? The most prominent and specific cognitive distortions in psychosis are a jumping to conclu sions bias, overconfidence and a bias against disconfirmatory evidence. What is the evidence for metacognitive training in psychosis? The latest and largest meta-analysis by Penney et al. (JAMA Psychiatry, 10.1001/ jamapsychiatry.2022.0277) considered 40 studies (n = 1816). Metacognitive therapy (MCT) was associated with reduced delusions (primary outcome, medium-to-largest effect size), hallucinations, cognitive biases, negative symptoms as well as improved self-esteem and functioning. Clinical guidelines in Germany now recommend the training for the treatment of schizophrenia. Are there any contraindications for MCT in psychosis? For patients with inappropriate behaviour, severe formal thought disorder and those who are not able to attend a 45-minute session, we recommend treatment with either individual ized MCT (MCT+; https://www.uke.de/mct_plus) or MCT-acute (https://www.uke.de/mctacute). Prevention and early detection are becoming increasingly important in (mental) healthcare. Can you give some examples of recent developments in the prevention area of psychological healthcare? In what ways can prevention and early detection be improved in your field of expertise? We have developed the app COGITO (free, no tracking, no registration) to accompany MCT (www.uke.de/cogito). The aim of COGITO is to improve mental well-being and prevent psy chological problems. The app also has a program package for psychosis. Prevention and early detection must by all means instill hope; we recommend that treatment of help-seek ing individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized (therefore, MCT needs to be carefully adapted as well) as it is only one of many possible outcomes, including full remission (0.1017/S0033291719001740).

Simon Blackwell Simon Blackwell is a postdoctoral researcher in the department of Clinical Psychology and Experimental Psychopathology at the University of Göttingen, Germany. He has a broad interest in the process of developing and testing evidence-based psychological interventions, and in particular how we can make this process more efficient. His research also has a particular focus on positive mental imagery and its potential use within psychological interventions. 20

You have been investigating opportunities for more rapid treatment development. One of these is the ‘leapfrog’ trial. Can you explain this method? In a ‘leapfrog’ trial design, multiple treatments (or multiple versions of one treatment) can be tested simultaneously, with data analyzed on a continuous basis using sequential Bayesian analyses. Ineffective treatments are rapidly identified and discarded, whereas effective treatments are ‘promoted’ to become the new control condition. New treatment arms informed by the latest research findings can be introduced into an ongoing trial as it progresses. The leapfrog design thus provides a flexible framework for ongoing treatment development and optimization that is much faster than the standard treatment development process and requires far fewer resources in terms of time, money, and participant numbers. You have actually tested this method in anhedonia. What were your main findings? Our main aim with our completed leapfrog trial was to demonstrate the leapfrog method and test its feasibility in a real-world treatment development application. Here we used it to develop an anonymous internet-delivered cognitive training intervention that aimed to improve anhedonia, which is a particularly treatment-resistant symptom of depression. We were able to test four potential versions of this intervention and identify the one that seemed most promising. Encouragingly, the leapfrog design appeared feasible to implement in this treatment development context, and we could observe the advantages of the design we had identified on paper (e.g. reduced participant numbers) come out in practice. Are there any limitations or risks to the leapfrog method? The leapfrog design will provide more advantages in terms of efficiency in some circum stances than in others, and this needs to be taken into account when considering whether to use the design and how exactly to implement it. Further, effect-size estimates produced when using sequential analyses can be biased, so researchers need to be aware of this when interpreting their results. Finally, there may be some practical challenges in implementing some aspects of the design in certain therapeutic settings (for example adding/removing a treatment arm, keeping therapists blind to the outcomes of sequential analyses), so these need to be thought through and planned carefully beforehand.

Niklas Törneke

Niklas Törneke is a Swedish psychiatrist and licensed psychotherapist with more than thirty years of experience in clinical work. He belongs to the original group of peer-reviewed ACT trainers and is an awarded fellow of the Association of Contextual Behavioral Science (ACBS). Alongside his own clinical work he has been training and supervising other psychotherapists both in Sweden and internationally for many years. He has authored and co-authored several book chapters and books with special focus on applying basic behavioral principles to everyday clinical work.

One of your fields of expertise is the use of metaphors in clinical practice. Why is metaphor use so important and helpful in conversation with clients? Do you have an inspiring example? First of all there is no way to avoid using metaphors in clinical work. Metaphor, according to modern research in linguistics and cognitive science, is such a basic building bloc of human language (note the metaphor in this sentence: ‘building block’, as if language is a building.). One area where this is especially true is private (inner’’) experiences, such as emotions, thoughts, memories etc. Typically a central aspect of therapy. Secondly, in therapeutic talk metaphor offers an opportunity to support a central process of psychological change; unhooking (decentering, defusion) from problematic self-instructions that tend to influence human behaviour. Relational frame theory (RFT) is often described as a shift towards a new understanding of language and cognition. How are RFT concepts related to ACT, for example? There is no absolute need for therapists to know RFT. RFT is a new and potentially helpful way of describing the effects of human language on human behaviour more generally. Primarily it is a scientific tool to tackle this central aspect of human life. But it does give some new ideas on what psychological problems are (a side-effect of language) that support modern trends in psychological treatment. One is the view that psychological problems are highly affected by the way we learn to interact with our own responding, and especially the subtle part typically referred to as thoughts, emotions, memories and bodily sensations. Rather than the content of those experiences, which has been the more common position of CBT. This has implications for therapeutic strategies and techniques.

PART II SUMMARIES OF SYMPOSIA

Cultural adaptation of psychological interventions Outcome differences between ethnic groups underline the need for adaptation

What do we know about the effect of ethnicity on treatment outcome and how do we go from there? In an interesting symposium, five speakers presented their data and advocated a greater awareness of the role of ethnicity in treatment. 24

How is it possible that a symposium virtually identical to the topic of this year’s EABCT gath ers so little interest? In a nearly empty hall, researcher Rob Saunders kicked of a symposium that should have been filled to the brim. We are all aware that individuals from ethnic minor ities generally yield worse treatment outcomes. But are specific ethnic minorities at a greater risk? And how can we ameliorate this? Relying on a large dataset based on data from the national NHS TTad program (the new and improved IAPT), Saunders found that, compared to the white ethnicity group, all other eth nicity groups yield lower chances of reliable recovery. Fortunately, Saunders also shared some good news, namely that the NHS TTad data show that differences in outcome across ethnicity have gradually started to diminish. In addition, confounding variables such as sociodemographic background as well as treatment factors also seem to attenuate some of the differences, indicating that not all effects are an immediate result of ethnicity. Religion However, the demarcation of ethnicity is not an easy matter. Joshua Buckman, the second speaker in the symposium clarified this in his talk. Instead of ethnicity, Buckman chose to investigate the role of religion in treatment outcome, arguing that religion plays a crucial role in mental health and recovery from mental health problems for people with faith beliefs. More specifically, Buckman looked at the results of NHS TTad service users on Muslim people in general and Muslim men in specific and compared them to Christian individuals. The results were very similar to those of Saunders. Overall, Muslims show poorer treatment out comes, although Buckman did not find evidence to suggest higher dropout rates for Muslim men. Even more disturbing was the finding of a higher likelihood of bad outcomes.

Religion plays a crucial role in mental health and recovery from mental health problems for people with faith beliefs.

Therapists should be stimulated to make cultural sensitivity part of the therapeutic relationship. As most of these issues are well acknowledged in clinical practice, Buckman was also able to look at the effects of local initiatives aimed at improving outcomes for Muslim men. Fortunately, these initiatives do suggest that improvements are possible, although there still is a long way to go. Adapting interventions Findings as those provided by Saunders and Buckman underline the importance of cul ture-adapted evidence-based interventions. And there are in fact several ways to tailor inter ventions. In order to categorize adaptations and come to conclusions as to their effectiveness, Laura Arundell and colleagues developed a typology of adaptations, subdivid ing them into therapist-related adaptations, content-related adaptations and organisa tion-specific adaptations. Based on this typology Arundell found that organisation-specific adaptations generally have large effects on outcome improvements. Therapist-related adaptations and content-related adaptations yield lower effects; in the small to medium category. What does this mean for clinical practice? According to Arundell, cultural adaptation proto cols and frameworks should be embedded into clinical practice. In addition, therapists should be stimulated to make cultural sensitivity part of the therapeutic relationship. Finally, Arundell argues for more options in the routing, formats, modalities and location to support patients in their needs. Chinese population Data on a different group came from Sying Lyndsey Li, who talked about her meta-analysis on the efficacy of culturally adapted psychological therapy for ethnic Chinese people. In addition to the typology of Arundell, Li also differentiated between culturally modified inter ventions and culturally specific interventions, the latter being specifically designed for a cul turally identified subgroup. For example, whereas a culturally modified intervention for ethnic Chinese people could include Tai chi as a way of behaviour activation, a culturally specific program designed for ethnic Chinese people would incorporate traditional Chinese medicine and Chinese philosophical teachings. Her meta-analysis yielded interesting results. All adaptation types and approaches resulted in benefits in symptom reduction, well-being and lower dropout rates compared to active control groups. As such, Li argues that evidence-based interventions developed in North America and Western Europe can indeed be effective in treating the ethnic Chinese popula tion, provided they are modified to fit the needs of this group.

Spain and Dominican Republic The symposium concluded with a contribution by Roger Munoz, who investigated the effects of a cultural adaptation of the NHS TTad program in Spain and the Dominican Republic. Although the exact nature of the cultural adaptations were unclear, Munoz added to the evi dence base that cultural adaptation of psychological interventions are feasible and effective.

KEY MESSAGES 26

• • •

Ethnic as well as religious subgroups are at risk of lower treatment outcomes. Cultural adaptations of evidence-based interventions yield more positive outcomes for minority groups. Cultural adaptations can be subdivided into therapist-adaptations, content-adaptations and organisational adaptations. Of those, organisational adaptations seem to yield the largest effect in terms of outcome improvement.

Metacognitive training for psychosis Open source training is effective in ameliorating positive symptoms

Metacognitive training (MCT) is a novel cognitive approach targeting positive symptoms in psychosis. In his keynote Steffen Moritz explained the content of MCT and the evidence for it.

There are quite a few definitions of metacognition in circulation, but they generally include the notion of thinking about one’s thinking. Steffen Moritz’s preferred definition is the one by Flavell (1976), which states that it is one’s knowledge concerning one’s own cognitive pro cesses or anything related to them. Flavell’s definition shows that metacognition is closely related to social cognition or Theory of Mind. Program So, what is MCT? MCT is a training program designed to correct cognitive biases subserving delusions, including (as Moritz puts it) the mother of cognitive biases: jumping to conclu sions. On a more practical level, MCT is designed as an easy-to-administer group training for four to ten patients and consisting of several modules. The modules all highlight the rela tionship between exercises and daily life/psychosis and include vignettes patients work through. As Moritz aptly showed in his keynote, the exercises in the program are designed to provide corrective experience in a playful, entertaining way. This prevents negative experi ences for patients. Basically, the program aims to plant the seeds of doubt. Recently, MCT has seen an addition of three modules. Instead of focusing on cognitive bias, the new modules are related to mood, dealing with stigmatization and self-esteem. According to Moritz, these are necessary additions, because many patients struggle more with these issues than with the symptoms of their psychosis. Perhaps the most appealing aspect of MCT is that it is open-source and free of charge. In addition, MCT is translated to many languages and has seen cultural adaptations. Interested psychologists can find the program at www.uke.de/mct and the app supporting it at www.uke.de/cogito_app.

Many patients struggle more with stigmatization and self-esteem than with the symptoms of their psychosis.

Mounting evidence The evidence for metacognitive therapy is growing, with over fourteen studies on the subject matter. Combined, they show that MCT has a small to moderate effect on delusions and posi tive symptoms and is highly acceptable to patients. As such, it may come as no surprise that some countries have started including MCT in their treatment guidelines. However, in 2014 a study by Oosterhout et al did not find evidence for the effectiveness of MCT. Investigating this in more depth, Moritz found the patients in this study were in the active phase of their delusions. Moritz therefore advices against using MCT for patients who are still in that active phase.

KEY MESSAGES • • •

MCT is an effective metacognitive training program for patients suffering from delusions. It highlights the relationship between exercises and daily life. MCT can be downloaded free of charge at www.uke.de/mct

The stigma of mental disorders Tailored evidence-based programs reduce stigma

Even after years of research on psychological well being in general and mental illness in specific, stigma is still very much present in society. In his keynote Keith Dobson proves himself a strong advocate for tailored evidence-based programs targeting stigma.

For some people its origin may be unknown, but historically the term ‘stigma’ referred to markings for disgraced individuals. In contemporary thinking, it often refers to the way indi viduals with mental and/or physical disorders are treated. A comprehensive understanding of the term is necessary to understand the negative effects people encounter. Components and types Stigma is generally thought to include three components: an emotional component (fear of the other), a component related to attitude (negative, stereotyped views) and a component related to discrimination (behaviours targeted to isolate or reject the other). In addition, stigma can refer to three separate types, of which social stigma is the most studied. Social stigma pertains to the negative views of others towards the person with a disability. The sec ond type of stigma, self stigma, includes internalized attitudes and beliefs the person with the disability holds. Structural stigma finally, pertains to the social systems and structure in place that limit the opportunity for equal involvement in society. Data In his keynote, Keith Dobson makes a strong case for a comprehensive approach to counter stigma in society, arguing that many individuals suffer as a consequence of it. Unfortunately, looking at the data on the subject matter, both research and practice are lacking. Take national models for example. Mental health services are skewed in such a way that equity of mental health services are compromised. In addition, few countries collect national statistics on the level of stigma perceived by people that suffer from mental illness. More importantly, some nationwide programs that are implemented in order to reduce stigma are thoroughly lacking in evidence. According to Dobson, this is especially the case with media campaigns targeting public information. Although they tend to produce small effects, these erode quickly after the campaign has ended. As such, Dobson states, those campaigns are expensive as well as inefficient. A different, but equally problematic effect is visible in campaigns on myth busting. Whereas many people tend to recall the myth that is presented after the campaign, the corrective information is less likely to stick, which may actually induce stigma. Tailored programs So, if these anti-stigma campaigns do not work, what does? In the remaining part of his key note, Dobson presented data on Opening minds, a program based on a combination of CBT

principles and psychoeducation. Specific applications have been developed to target youth, health care, the workplace and media. Across these different applications, however, the pro gram contains common elements such as group discussions, contact-based education, didactic information, skills teaching, talk about coping and education on the mental health continuum model. It is this last element, according to Dobson, that seems to be vital. Instead of classifying individuals as healthy or ill, the continuum explains problems in terms of a continuum and emphasizes the fluidity of one’s position on it.

Cost effectiveness studies are necessary to really understand the potential of the program.

Effective Of course the million dollar question is whether the program is in fact effective. And indeed, not only does this seem to be the case, Dobson also shows the results are very robust. Irrespective of the exact study or targeted group or form of application (virtual versus face to face), the program reduces stigma and improves resiliency skills. And although the effects do seem to wear off after a few months, significant effects remain visible. It does however, sug gest the need for booster sessions. In his closing remarks, Dobson explained the next research steps. Although the program’s evidence base is growing, he does see a lot of opportunity to further improve on it. For instance, are all components of Opening minds equally necessary for its effectiveness? In addition, cost effectiveness studies are necessary to really understand the potential of the program. But if one thing is clear, it is that stigma has a strong opponent in Dobson.

KEY MESSAGES • • •

Stigma is a serious, multidimensional problem throughout the world. Many stigma reducing programs do not have sufficient evidence to justify their use. Targeted programs based on CBT principles and psychoeducation are effective and may offer a solution.

Body Dysmorphic Disorder in youth; what works and what doesn’t Body Dysmorphic Disorder (BDD) is defined as an excessive and intense preoccupation with perceived flaws in physical appearance. These preoccupations often relate to facial features, such as flaws around the nose, eyes and skin. What’s interesting about BDD is that these ‘flaws’ are often completely unobservable to other people. The latest insights in BDD research were discussed during the symposium ‘Improving the detection and treatment of BDD in youth’. Researchers answered questions like: how can practitioners more effectively detect BDD? Can BDD be treated with online CBT interventions and what factors moderate BDD treatment?

(Under)detection The highly impairing nature of BDD is clear: studies from clinical settings show that about one in three young people with BDD dropped out of education because of their symptoms. Even more concerning: an estimated one in four young people with BDD attempt suicide. BDD is highly under-detected and under-diagnosed. One important factor causing under-de tection is that, among adolescents, it can easily be dismissed as a normal development phase. What can clinicians do to spot these signs of BDD more effectively? Georgina Krebs from the University College London advocates one of the simplest solutions: just ask the patients. A question like: ‘do you worry a lot about your appearance?’ is a good start. A follow-up semi-structured interview is the gold standard for further assessment, but this is often time-consuming. Surprisingly, hardly any self-report questionnaires have been evaluated in young people for BDD. Krebs and colleagues evaluated the Body Image Questionnaire- Child and Adolescent version (BIQ-C, nine items), in a non-clinical (479 young people) and clinical sample (129 young people with confirmed BDD) and investigated the factor structure, internal consistency, convergent validity and treatment sensitivity.

Just asking the patient a simple question like: ‘do you worry a lot about your appearance?’ is a good start. What did the results show? The researchers identified a two-factor structure in both samples. The internal consistency is good, both for the total score (Cronbach’s alpha 0.83-0.88) and the two factors (Cronbach’s alpha ranging from 0.78-0.84) in both samples. Convergent

validity was high showing Pearson correlations of 0.82 with the Appearance Anxiety Inventory (AAI) and 0.65 with the Revised Children’s Anxiety and Depression Scale. The BIQ-C score changed significantly from pre to post-treatment (CBT without medication) so it is effective in picking up changes during treatment. Change score of the BIQ-C and the BDDYBOCS-A (Yale-Brown Obsessive-Compulsive Scale for BDD) were compared and showed a large correlation of 0.7. This confirms that the BIQ-C is suitable for assessing BDD symptoms in young people and has the potential to aid detection and diagnosis.

Online solutions Another silver lining is that there are effective treatments for BDD. However, there is little research on BDD treatment in adolescents. This has to do with the various barriers hindering adolescents from seeking and receiving treatment. Fear of stigma and shame are two of them. This is where internet-based interventions come in. Michaela Schmidt from the Osnabrück University set out to test the efficacy of a thera pist-guided, online CBT-based intervention for adolescents with BDD, called the ImaginYouth intervention (n = 13). Effects were compared with an active control group (n = 16) who com pleted an online self-help intervention. Youngsters in the age from five to 21 years and diag nosed with BDD were included. The ImaginYouth intervention consisted of twelve weekly sessions with homework assignments (covering, among other things: psycho-education, cog nitive restructuring, avoidance behaviour, relapse prevention) with the possibility to interact with a psychologist online. The high hopes for online treatment of BDD were confirmed. Results showed a significant reduction of therapist-rated BDD symptom severity and self-reported symptoms between pre- and post-treatment for the ImaginYouth intervention group. Although the control group also showed a modest reduction of symptoms, the online therapist-guided group from ImaginYouth was superior. Replication with a larger number of participants is needed and results from the six months follow-up data are pending. OCD & BDD The treatment of Obsessive Compulsive Disorder (OCD) is complicated by comorbidities. In adult samples, it is expected that about 10% of adults with OCD also have BDD, which is four times the prevalence in the general population. The research on understanding the comor bidity of OCD and BDD is very limited. When Prof. Laura Farrell was conducting a large treat ment study of young people with OCD, she was interested in the co-occurrence of BDD in her sample and the impact on the clinical expression of OCD and treatment outcomes. The trial consisted of 107 young people (ages 7-17 years), about 50% of whom were girls. Three subgroups were formed, those with: OCD and comorbid BDD (n = 10), OCD without comorbid BDD (n = 10) and OCD without any comorbidity (n = 10). All participants received a three-hour intensive CBT-ERP session every three weeks. Additionally, they each received a booster session one month later.

In this OCD sample, BDD occurred in 9,35% of youngsters. And notably, youth with comorbid BDD were older (mean age of ‘comorbid BDD’ = 13.8 years compared to ‘no BDD’ = 11.75 years). BDD symptoms were positively correlated to greater OCD impairment (r = .36) and symptom frequency (r = .41). As for the OCD with comorbid BDD compared to those without BDD or any comorbidity: the OCD with comorbid BDD participants experienced higher social impairment in school and social domains and had higher obsessional and total OCD severity. Overall, CBT-ERP results showed that BDD symptoms significantly decreased. However, in the OCD and BDD subgroup, BDD symptoms did not reduce. The researchers conclude that youth with comorbid BDD symptoms may not achieve recovery from OCD following CBT-ERP, but an intensified modular treatment may be indicated for this group. (Excessive) motherly love One of the factors that can impact treatment outcome in OCD, and possibly BDD, is family accommodation. This refers to the behavioral changes parents perform to reduce their child’s distress (providing reassurance or assisting avoidance of feared objects or situations). Up to 99% of parents will accommodate their child’s OCD symptoms. Considering the over lap of OCD and BDD, Amita Jassi and colleagues investigated family, in particular maternal, accommodation in BDD and associations with treatment outcomes. Of the total sample of 131 adolescent girls, 70 of them received CBT. Maternal accommoda tion in BDD was very common; 74% of mothers reported daily accommodation, with 60% providing reassurance and 55% assisting in their child’s avoidance behaviours. Results showed that greater levels of maternal accommodation were associated with poorer child global functioning and greater maternal psychopathology. However, maternal accommoda tion was not associated with BDD symptom severity. Most importantly: maternal accommo dation did not predict outcomes following BCT for BDD. Jassi and her colleagues conclude that maternal accommodation does not have the same relationship with BDD symptoms as evidenced in other disorders, such as OCD. Consequently, parental involvement in treatment of BDD may not be as necessary as it is in OCD.

KEY MESSAGES • • • •

The Body Image Questionnaire – Child and Adolescent version (BIQ-C) is suitable for assessing BDD symptoms in young people. Online therapist-guided interventions, such as ImaginYouth, seem effective for BDD symptom treatment and are superior to self-help online interventions. OCD and BDD frequently occur together and BDD symptoms are associated with greater OCD impairment. More maternal accommodation of BDD symptoms is related to poorer child functioning but maternal accommodation does not predict CBT outcome for BDD.

The intergenerational transmission of mental illness: intervening interventions

Parental mental disorders potentially launch a wave of risk factors that predict mental health difficulties in their offspring. Preventive interventions increasingly focus on both the parents with mental health problems and their children. From online interventions to interventions aimed at first-time parents and their infants: feasibility and effectiveness studies show promising results to improve the mental health of struggling families worldwide. The symposium ‘Novel interventions focused on preventing the intergenerational transmission of mental illness’ gives an interesting overview.

Lowering barriers from home Why does anxiety run in families? According to Abigail Dunn from the University of Sussex, genes are only a fraction of the story. More importantly, research shows that cognitive biases are at work and these biases extend into their child’s world. For example, anxiety impacts upon parenting styles. Anxious parents are much more likely to be overprotective of their child. Dunn and colleagues conducted an RCT to investigate the effectiveness of a one-day work shop aimed at anxious parents. Among other things, parents were taught about ‘parenting hotspots’, such as overprotection and modelling and how these can affect their children’s behaviour. The workshop was effective at lowering the child’s anxiety at twelve months post-intervention compared to children in the control group. But Dunn highlighted some problems with interventions like these, one of them being: most anxious people never seek out mental health services. To lower help-seeking barriers for anxious people, Dunn and colleagues developed a fully digital intervention aimed at increasing confident parenting styles. It consisted of eight mod ules and interactive quizzes and videos. There was no therapist support; participants received automated emails and text reminders to encourage them to keep logging on during the intervention. 1811 parents with high anxiety and their children between the ages of 2-11 years were included. 900 participants were randomized to receive the intervention and the other 911 participants were a no-treatment control group. What were the results for this fully online intervention? Engagement was variable; only 20% of participants completed the entire programme. For those who completed the intervention, (high) effect sizes for anxiety levels ranged between 0.7 and 1.2. Results indicated that better engagement resulted in significantly better outcomes, so Dunn emphasizes that efforts should be made to optimize engagement.

Children of parents with mental illness can be considered as the next generation of patients with mental illness. Prevention is key Markus Stracke and colleagues from the Philipps University Marburg in Germany took it one step further, stating that children of parents with mental illness can be considered as the next generation mental illness patients. These children and their parents are therefore a spe cific target for preventive interventions. Stracke set out to assess the effects of CBT combined with a positive parenting program (Triple P) versus CBT only on the mental health status of children (ages 1.5 to 16 years) of parents with mental illness as part of the COMPARE family trial. In total, 345 families were included with depressive and anxiety disorders as primary (parent) diagnoses. Both parents and teachers rated the children’s symptoms and functioning at the start, end and at six months post-intervention. According to teachers, treatment of the parental disorder with CBT results in child symptom reduction, but there are no significant group differences. However, parenting skills at six months follow-up seem better in the CBT + triple P group compared to the CBT only group. Targeting treatment for parents with mental difficulties seems to be key for the reduction of child symptoms. Results of clinical interviews and mediation analyses on effects of changes in parenting skills are pending. Keep an eye out for the COMPARE study! Triple P continued: parents with psychosis As is the case with depression and anxiety, Triple P and similar parenting interventions seem acceptable and effective for parents with psychosis as well. But there is a general lack of research into these interventions for parents experiencing severe mental illnesses. Lynsey Gregg from the University of Manchester earlier studied Triple P for psychotic par ents, focusing on normalizing parenting problems and creating a safe and positive environ ment. It was delivered by research assistants at home, in ten weekly sessions. Results were promising, showing increased confidence in the parents and decreased problematic behav iour in their children. Momentarily, Gregg and colleagues will start a new project: a feasibility study into self- directed Triple P for parents with psychosis (PIPPA study). Among other things, barriers and facilitators of intervention will be studied, as well as the impact of Triple P on parental stress, mental health, parental self-efficacy and child behaviour. Parents are to be given

access to either self-guided online Triple P or a workbook version which they complete in fif teen weeks. 75 participants will be randomly allocated (when recruitment is finished) to either receive Triple P plus TAU or TAU alone. Parents will be assessed using several meas ures (baseline, post-treatment and follow-up) including the Parenting Stress Index (PSI), and the Positive and Negative Syndrome Scale (PANSS). What’s next? Study outcomes from PIPPA will be used to inform the design of a larger trial and eventually allow for the rapid adoption within services, should Triple P be determined (cost) effective. In the end, Gregg and others aim to reduce the stigma of discussing chal lenges in parenting. This allows parents to ask for help with parenting when they need it and for that support to be available. 36

KEY MESSAGES •

• •

A fully digital intervention aimed at improving anxious parenting styles, can effectively lower anxiety levels in children. Engagement with the intervention is key for optimal effects. CBT combined with Triple P for parents with mental health issues improves child functioning and parenting skills at six months follow-up. A feasibility study for Triple P aimed at parents with psychosis is starting late 2023 and will examine barriers, facilitators and effectiveness of Triple P for psychosis.

Digital interventions; what should we keep in mind? Research on digital mental health has been growing exponentially over the last ten years. These multiple studies share a main question: are digital mental health interventions effective? But there are other interesting questions to be asked: what are ways to design and develop digital interventions to increase engagement? And last but not least, how can laboratory research tasks be implemented in clinical practice to actually affect behaviour? This was discussed in the symposium: ‘Digital mental health interventions: design, efficacy, personalization and implementation’. A heads-up: research has come a long way, but there is still a lot of future work ahead.

Personalization is key Purported benefits of digital interventions are its low cost-effectiveness, scalability and a feeling of autonomy they provide for the patients. These benefits are shown in multiple stud ies but there is, however, little evidence on fully autonomous digital interventions without personal contact. Ben Ainsworth and colleagues from the University of Southampton first conducted a system atic review of 24 fully autonomous interventions to investigate patient engagement. These interventions were based on CBT, mindfulness, ACT and positive psychology. They concluded that all interventions had a small but significant effect on the outcome measures, but only 16% of studies reported optimal engagement (people engaging with the interventions as developers and practitioners intended). Socio-economic status (SES) was an important mod erating factor; low-SES patients, in particular, did not benefit from the various interventions. What are ways to improve patient engagement in digital interventions? Ainsworth and col leagues are using the Person Based Approach (PBA) to design and research digital interven tions. Central to this is understanding the perspective of people and stakeholders who will actually use the intervention in order to improve uptake, adherence and outcomes.

We really need to think about ways to get people to engage with digital interventions.

For example, while developing a digital student mental health app, they first conducted a number of studies in order to highlight barriers for users. These are then used to develop guiding principles central to the design of a particular intervention. ‘Students feel that well-being support at universities is aimed at those experiencing severe distress’ is an exam ple of a barrier. A guiding principle for this would be: ‘to challenge the belief that well-being support is aimed at only those who struggle’. Ainsworth stresses the importance of identifying a clear target behaviour when developing digital interventions, as well as tailoring an intervention to the target population. Fully digi tal interventions are not always the answer and, in terms with PBA: personalized support should be provided for those who need it. 38

(STOP) paranoia Researchers at King’s College London are a step beyond designing and developing, namely in the stage of testing a new digital intervention. During the EABCT conference, the concept of paranoia needs no elaborate introduction. It suffices to describe it as an exaggerated distrust of others or a feeling of being persecuted. It is prevalent in a range of disorders and more effective and accessible treatments are needed. A digital intervention focused on paranoia (STOP) was developed and is currently being tested by Carolina Fialho and her colleagues at King’s College London. They set up an effec tiveness study testing the twelve-session STOP mobile app based on cognitive bias modifica tion at different doses (six versus twelve sessions versus a control group). All STOP-items (40 items each weekly session) follow a similar structure: they start with a paranoia-provoking scenario and are followed by a word completion exercise. These are meant to encourage par ticipants into making a more positive or neutral interpretation of the scenario. In total, 273 participants are included between 18 and 65 years of age, who are currently not receiving similar psychological intervention and are not experiencing extreme paranoia. The primary clinical outcomes are scores on various paranoia scales (Paranoia Scale, Green Paranoid Thoughts Scale, among others). Next steps are data analysis to determine the effi cacy of the STOP intervention, planned for 2024. Subsequently, effectiveness will be tested in clinical practice after finishing this effectiveness study in 2025. A little more patience is required, but good things come to those who wait. Joysticks In contrast to the other studies discussed in this symposium, Mike Rinck from the Radboud University Nijmegen points out that his research does not involve ‘fancy apps’ but is rather ‘old-school’ using joysticks and a computer screen. And after all, does one really need more to study fundamental approach and avoidance tasks? Specifically, Rinck and colleagues studied alcohol-approach bias modification, whereby par ticipants use a joystick to either push away or pull towards an alcoholic beverage showed on screen. To modify the task, participants are instructed, for example, to push alcoholic bever ages away repeatedly in this manner. From previous research, Rinck and colleagues were aware that alcohol consumption can indeed be affected by bias modification, so it was worth investigating this for heavy drinking students.

The positive effect of digital interventions was entirely driven by people with high-SES status. In their RCT, Rinck and fellow researchers recruited 214 currently abstinent, alcohol use dis order patients from a local clinic. They were allocated to either an active alcohol-avoidance training group with treatment as usual (TAU; which consisted of CBT), a placebo training group combined with TAU, and a no-training group with TAU. At one-year follow up, the par ticipants in the active training group showed a 13% reduction in relapse rate compared to the two control groups. In various replication studies, Rinck and other colleagues found simi lar reductions in relapse rates, ranging between 8-12% in the active groups (with sample sizes varying from 83 to 1405 participants). The next step, which Rinck and others are in the process of finalizing, is testing the training during regular treatment. Preliminary results show that implementation is possible, although reduction in relapse rates appear to be smaller in these trials. Of course, there is always room for improvement. The researchers are looking into the number and temporal spacing of training sessions, for example. And a notorious question that keeps coming back to most research: what are the working mechanisms; what exactly is the helpful ingredient in the active avoidance training? These questions give rise to new research opportunities and projects to be discussed during the next EABCT conference.

KEY MESSAGES • • •

A Person Based Approach can improve uptake, adherence and outcomes of digital interventions. A fully digital intervention focused on paranoia (STOP) is being tested for efficacy. Next step: testing in clinical practice. Active avoidance-training is effective in reducing relapse rates among patients with alcohol use disorder compared to control conditions.