SCIENCE-BASED THERAPY

This is the first book to analyze empirically supported treatments by using the newest
criteria from the American Psychological Association’s Society of Clinical
Psychology, Division 12. Clinicians, scholars, and students all need to stay updated
on the treatment research, and this book goes beyond providing updated treatment
information by pointing readers to other useful treatment manuals and websites for
continuing to stay up to date. The chapters, all written by prominent experts, highlight
the best available evidence for specific disorders by breaking treatments down into
credible components. With an emphasis on treatments for adults, chapters also share
information about treatments for youth. Other variables that influence treatment are
discussed, including assessment, comorbidity, demographics, and medication. Each
chapter also corresponds with a chapter in the companion book, Pseudoscience in
Therapy, presenting a full picture of the evidence base for common treatments.

STEPHEN HUPP is a professor, psychologist, author, and editor of the magazine

Skeptical Inquirer. He has received the Great Teacher Award and the Champion for
Diversity Award from Southern Illinois University Edwardsville, and holds
a Guinness World Record for the “longest line of books.”

DAVID F . TOLIN is the author of more than 200 scientific journal articles and several
books, including Doing CBT. He has received the Award for Distinguished
Contribution to the Science of Psychology, the Award for Distinguished Contribution
to the Practice of Psychology, and the Award for Lifetime Contribution to Psychology
from the Connecticut Psychological Association. He is the past-president of the
Association for Behavioral and Cognitive Therapies, and past-president of the
Clinical Psychology Division of the American Psychological Association.
Other Books in this Series
• Pseudoscience in Therapy: A Skeptical Field Guide
• Pseudoscience in Child and Adolescent Psychotherapy: A Skeptical Field Guide
• Child and Adolescent Psychotherapy: Components of Evidence-Based Treatments for Youth and
Their Parents (a second edition is forthcoming with the revised title, Science-Based Therapy for
Children and Adolescents)

Other Books by Stephen Hupp

• Investigating Clinical Psychology: Pseudoscience, Fringe Science, and Controversies
• Investigating School Psychology: Pseudoscience, Fringe Science, and Controversies
• Investigating Pop Psychology: Pseudoscience, Fringe Science, and Controversies
• Thinking Critically about Child Development: Examining Myths and Misunderstandings
• Great Myths of Child Development
• Great Myths of Adolescence
• Dr. Huckleberry’s True or Malarkey? Superhuman Abilities

Other Books by David F. Tolin

• Doing CBT: A Comprehensive Guide to Working with Behaviors, Thoughts, and Emotions
• The Oxford Handbook of Obsessive-Compulsive and Related Disorders
• The Big Book of Exposures: Innovative, Creative, and Effective CBT-Based Exposures for Treating
Anxiety-Related Disorders
• CBT for Hoarding Disorder: A Group Therapy Program Workbook
• Treating Trichotillomania: Cognitive-Behavioral Therapy for Hairpulling and Related Problems
• Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions
• Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding
 SCIENCE-BASED THERAPY
Raising the Bar for Empirically Supported Treatments

Edited by

Stephen Hupp
Southern Illinois University Edwardsville

David F. Tolin
Institute of Living
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DOI: 10.1017/9781009086264
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Names: Tolin, David F., editor. | Hupp, Stephen, editor.
Title: Science-based therapy : raising the bar for empirically supported treatments / edited by David F.
Tolin, Southern Illinois University, Edwardsville, Stephen Hupp, Institute of Living.
Description: New York : Cambridge University Press, [2024] | Includes bibliographical references and
index.
Identifiers: LCCN 2024000815 | ISBN 9781316514566 (hardback) | ISBN 9781009087940 (paperback) |
ISBN 9781009086264 (ebook)
Subjects: LCSH: Evidence-based psychotherapy. | Mental illness – Treatment.
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To my son, Henry Thomas Hupp – I’m proud of everything you do. (S. H.)
To Fiona, James, and Katie, with love and thanks. (D. T.)
 Contents

List of Tables page ix

List of Contributors x
Preface xiii
Acknowledgments xvi

1 What Is Science-Based Therapy? 1

David F. Tolin and Stephen Hupp
2 Depressive Disorders 11
John R. McQuaid and Alfiee Breland-Noble
3 Bipolar Disorder 30
Monica Ramirez Basco
4 Anxiety Disorders 47
Dean McKay
5 Obsessive-Compulsive Disorder 64
Dean McKay
6 Posttraumatic Stress Disorder 81
Carmen P. McLean and Eve A. Rosenfeld
7 Dissociative Disorders 105
Damla E. Aksen and Steven Jay Lynn
8 Pain 122
Laura Nelson Darling, Kristine Lee, and John Otis
9 Eating Disorders 139
Jamie M. Loor, Jennifer A. Battles, Brooke L. Bennett,
Danae L. Hudson, and Brooke L. Whisenhunt
10 Insomnia Disorder 159
Parky Lau, Onkar Marway, and Colleen Carney

vii
viii Contents

11 Sexual Dysfunctions 175

Amy D. Lykins and Marta Meana
12 Substance Use Disorders 193
Victoria E. Stead, Andrew B. Lumb, Jennifer Brasch,
and James MacKillop
13 Cognitive Loss 218
Claudia Drossel
14 Antisocial Behavior 246
Devon L. L. Polaschek
15 Borderline Personality and Other Personality Disorders 265
Joel Paris
16 Psychosis and Schizophrenia 282
Elizabeth Thompson, Katherine Visser, Madeline Ward, and Brandon
A. Gaudiano
17 Autism Spectrum and Intellectual Developmental Disorder 304
Frank R. Cicero
18 Attention-Deficit/Hyperactivity Disorder 329
Mary V. Solanto
19 Tic Disorders 344
Kirsten Bootes, Emily Braley, and Michael B. Himle
20 Couples Discord 364
Matthew D. Johnson and Erin F. Reto
21 Psychotherapy Relationships 381
John C. Norcross and Christie P. Karpiak
Postscript: Evaluating Treatments with the Science-Based Tolin
Criteria: A Call to Action 399
Cassandra L. Boness, Stephen Hupp, and David F. Tolin

Index 406
 Tables

21.1 Summary of meta-analytic associations between relationship

components and distal psychotherapy outcomes page 384
22.1 Well-established empirically supported treatments: Chambless
criteria 400
22.2 Empirically supported treatment status: Tolin criteria 402

ix
 Contributors

Damla E. Aksen is a clinical psychology doctoral stu- Alfiee Breland-Noble is the founder of the mental health
dent at SUNY Binghamton University (SUNY). Her nonprofit The AAKOMA Project, which focuses on
research focuses on working memory, emotion dysre- improving the mental health needs of intersectional
gulation, dissociation, and impulsivity. Youth of Color via research, outreach, and media.
Dr. Breland-Noble is the editor of the book Community
Erin F. Reto received her doctorate from Binghamton
Mental Health Engagement with Racially Diverse
University, State University of New York. Her research Populations.
on intimate partner violence led to a well-regarded
review article in the journal Trauma, Violence, Colleen Carney is a professor of psychology at Toronto
& Abuse. Metropolitan University. Dr. Carney is author of the
book Goodnight Mind: Turn off Your Noisy Thoughts &
Monica Ramirez Basco is a clinical psychologist and Get a Good Night’s Sleep.
founding fellow of the Academy of Cognitive Therapy.
She is author of the book The Bipolar Workbook: Tools Frank R. Cicero is an associate professor and program
for Controlling Your Mood Swings, Second Edition. director for the behavior analysis programs at Seton Hall
University, New Jersey. He has published works in the
Jennifer A. Battles is a primary care clinical psycholo- fields of behavior analysis and autism over the past
gist and a member of the Interdisciplinary Eating several decades.
Disorder Team at the VA St. Louis Healthcare System.
Laura Nelson Darling is a doctoral student of clinical
Brooke L. Bennett is an assistant professor at Clemson psychology at Boston University. Her research and
University.
clinical work centers on evidence-based treatments for
Cassandra L. Boness is a licensed clinical psychologist anxiety and related disorders.
and a research assistant professor at the University of Claudia Drossel is an associate professor of psychology
New Mexico Center on Alcohol, Substance use, And at Eastern Michigan University. She is coeditor of the
Addictions (CASAA). Dr. Boness’ expertise is related to book Applications of Behavior Analysis in Healthcare
the etiology, assessment, and treatment of substance use
and Beyond.
disorder.
Brandon A. Gaudiano is a professor in the Department
Kirsten Bootes is a doctoral student in clinical psych-
of Psychiatry and Human Behavior at the Warren Alpert
ology at the University of Utah. Medical School of Brown University and in the
Emily Braley is a doctoral student in clinical psychology Department of Behavioral and Social Sciences at the
at the University of Utah. School of Public Health. He is also director of the
Transitional Outpatient Program at Butler Hospital, and
Jennifer Brasch is the lead for addiction psychiatry at a research psychologist at the Providence VA Medical
St. Joseph’s Healthcare Hamilton and Associate Center.
Professor in the Department of Psychiatry and
Behavioural Neurosciences at McMaster University. Michael B. Himle is an associate professor of psych-
Dr. Brasch is the past president of the Canadian Society ology at the University of Utah, where he teaches and
of Addiction Medicine. conducts research on tic disorders.

x
 List of Contributors xi
Danae L. Hudson is a professor of psychology at Onkar Marway is a doctoral student in clinical psych-
Missouri State University. She is coauthor of the books ology at Toronto Metropolitan University.
Revel Psychology 1st edition and Psychological
Disorders: A Scientist-Practitioner Approach, 5th Dean McKay is a professor of psychology at Fordham
edition. University. He is coeditor of the book Complexities in
Obsessive Compulsive and Related Disorders: Advances
Stephen Hupp is a professor of psychology at Southern in Conceptualization and Treatment.
Illinois University Edwardsville. He is editor of the book
Carmen P. McLean is a clinical psychologist at the
Investigating Clinical Psychology and editor of Skeptical
Inquirer: The Magazine for Science and Reason. National Center for PTSD, Dissemination and Training
Division at the Palo Alto VA Health Care System and
Matthew D. Johnson is a professor of psychology and a clinical professor (affiliated) in the Department of
director of the clinical psychology PhD program at Psychiatry and Behavioral Sciences, Stanford
Binghamton University, State University of New York. University.
He is the author of Great Myths of Intimate
Relationships: Dating, Sex, and Marriage. John R. McQuaid is Chief of Psychology at the Palo
Alto VA Health Care System and a vice chair in the
Christie P. Karpiak is Professor of Psychology and Department of Psychiatry and Behavioral Sciences,
Department Chair at the University of Scranton. She is Weill Center for Neuroscience, University of California,
also a child clinical psychologist in part-time practice. San Francisco. He served as cochampion for the VA/
DoD Clinical Practice Guidelines for Major Depression.
Parky Lau is a doctoral student in clinical psychology at
Toronto Metropolitan University. Marta Meana is a professor of psychology at the
University of Las Vegas. She is past president of the
Kristine Lee is a doctoral student of clinical psychology Society for Sex Therapy and Research, associate editor
at Boston University. Her research interests focus on of the Journal of Sex Research, and was an advisor to the
increasing access to evidence-based treatments, specif- DSM-5 Sexual Dysfunctions Workgroup.
ically for marginalized youth of color.
John C. Norcross is Distinguished Professor of
Jamie M. Loor is a postdoctoral research fellow at the Psychology at the University of Scranton and Clinical
University of New Mexico Health Sciences Center with
Professor of Psychiatry at SUNY Upstate Medical
the Center for Healthcare Equity in Kidney Disease. University. He is author of numerous books, including
Andrew B. Lumb is a clinical and health psychologist in the third edition of Psychotherapy Relationships That
the Transitional Aged Youth Service, Substance Use and Work.
Concurrent Disorders Program at the Royal Ottawa John Otis is a research associate professor at Boston
Mental Health Centre and a faculty member in the
University. He is the author of the treatment manual
School of Psychology of the University of Ottawa. Managing Chronic Pain.
Amy D. Lykins is an associate professor of clinical
Joel Paris is an emeritus professor of psychiatry at
psychology at the University of New England in New McGill University in Canada. He is author of the book
South Wales, Australia. She is a consulting editor for the Treatment of Borderline Personality Disorder: A Guide
Journal of Sex Research and coeditor of the book series
to Evidence-Based Practice, Second Edition.
Critical Topics in Sexuality Research.
Devon L. L. Polaschek is a professor of psychology at
Steven Jay Lynn is Distinguished Professor at Binghamton
the University of Waikato. She is coeditor of The Wiley
University (SUNY). He is coeditor of the book Science and International Handbook of Correctional Psychology.
Pseudoscience in Clinical Psychology and coauthor of 50
Great Myths of Popular Psychology: Shattering Eve A. Rosenfeld is an advanced postdoctoral fellow at
Widespread Misconceptions of Human Behavior. the National Center for PTSD, Dissemination and
Training Division at the VA Palo Alto Health Care
James MacKillop holds the Peter Boris Chair in
System and at the Department of Psychiatry and
Addictions Research and a Tier 1 Canada Research Chair Behavioral Sciences, Stanford University
in Translational Addiction Research, and is Professor of
Psychiatry and Behavioural Neurosciences at McMaster Mary V. Solanto is Professor of Pediatrics and
University. Dr. MacKillop directs the Peter Boris Centre Psychiatry at Hofstra-Northwell School of Medicine,
for Addictions Research and the Michael G. DeGroote New York. She authored Cognitive-Behavioral
Centre for Medicinal Cannabis Research at McMaster Treatment for Adult ADHD: Targeting Executive
and St. Joseph’s Healthcare Hamilton. Dysfunction, a treatment manual for clinicians.
xii List of Contributors
Victoria E. Stead is a psychologist with the Young Medicine. He also maintains a private clinical and con-
Adult Substance Use Program within the Concurrent sulting practice.
Disorders Outpatient Service at St. Joseph’s Healthcare
Hamilton and an assistant professor (part-time) in the Katherine Visser is a clinical psychologist and a clinical
Department of Psychiatry and Behavioural assistant professor of psychiatry and human behavior at
the Warren Alpert Medical School of Brown University.
Neurosciences at McMaster University.
She is also a staff psychologist with the Lifespan
Elizabeth Thompson is a clinical psychologist and an Physician Group in Providence, RI.
assistant professor of psychiatry and human behavior at
the Warren Alpert Medical School of Brown University. Madeline Ward is a clinical psychology doctoral stu-
She also is a research scientist and staff psychologist at dent at Case Western Reserve University.
Rhode Island and Bradley Hospitals. Brooke L. Whisenhunt is a professor of psychology at
David F. Tolin is the founder and director of the Anxiety Missouri State University. She is coauthor of the books
Revel Psychology 1st edition and Psychological
Disorders Center at the Institute of Living and an adjunct
professor of psychiatry at Yale University School of Disorders: A Scientist-Practitioner Approach, 5th edition.
 Preface

I attended graduate school in the 1990s when the movement to define and identify
empirically supported treatments (ESTs) was really starting to take off. I fully
embraced the model then, as I do today, because I was already concerned about
some clinical practices that were commonly used despite research demonstrating they
were ineffective and sometimes even harmful. In fact, my concern about pseudo-
science in clinical psychology has grown stronger every year, leading me to publish
books about great myths, fringe science, and critical thinking. Those books ultimately
led to my recent role as the editor of Skeptical Inquirer: The Magazine for Science and
Reason.
The use of pseudoscience in clinical psychology is especially perplexing when
considered in the context of the large and growing number of available ESTs (see the
Postscript to this book for a summary). When a task force from the American
Psychological Association first defined well-established ESTs, they intentionally set
the bar at a somewhat rigorous but also achievable level. Over the course of three
decades, many treatments reached this bar and set a firm foundation for new develop-
ments and research endeavors.
It’s now time to raise that bar. Even though it was set at a reasonable level, given the
state of the literature three decades ago, the field has advanced tremendously. I sought
out David Tolin – former president of the Association for Behavioral and Cognitive
Therapies – as coeditor of this book because he’s helped lead the movement toward
setting a higher bar, colloquially referred to as the “Tolin criteria” – a term that I can’t
help but use even though he’s modestly shared he doesn’t love it. To be clear, the
Tolin criteria were created by a team including scholars such as Dean McKay, Evan
Forman, David Klonsky, and Brett Thombs, and greatly influenced by others such as
Cassandra Boness, Scott Lilienfeld, Steven Jay Lynn, Daniel David, and Guy
Montgomery. The biggest influencer of all was Dianne Chambless, who led the initial
task force comprised of a similarly impressive group of clinicians and scholars in
wisely (and bravely) setting the initial bar for ESTs. The development of the
“Chambless criteria” was a giant leap forward for science-based therapies.
xiii
xiv Preface

The Tolin criteria are meant to supplement, not supplant, the Chambless criteria,
and both models are well represented in this book. The Society of Clinical Psychology
(SCP), through their website (www.psychologicaltreatments.org), has been catalog-
ing well-established ESTs based on the Chambless criteria for many years. To date,
however, only a small number of treatments have been evaluated using the Tolin
criteria, and I’m aware of only a small number of future planned reviews using the
Tolin criteria. Thus, now is the time for more people to help us raise the bar by doing
more reviews, and if you would like to review a particular treatment for a particular
disorder, then please read the Postscript to this book for what to do next.
As you read through the chapters of this book, you’ll get a better understanding for
which treatments have the most research support. The chapters are written through the
combined lenses of the Chambless criteria and the Tolin criteria, with an emphasis on
high-quality research, systematic reviews, and credible components (or processes) of
ESTs.

Focus and Structure

This book focuses on therapy with adults, while another book in this series (Child
and Adolescent Psychotherapy [the forthcoming second edition will be titled
Science-Based Therapy for Children and Adolescents]) focuses on therapy with
youth. Chapter 1 defines ESTs, evidence-based practice, and science-based therapy.
The chapters that follow focus on diagnoses and issues that are commonly the focus
of clinical attention in an order that is generally consistent with how they appear in
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text
Revision. Almost all of the chapters include these sections:
• description of disorder(s) of focus
• etiology and theoretical underpinnings of treatment
• brief overview of treatments
• credible components of treatments
• approaches for youth
• other variables influencing treatment (i.e., assessment and diagnosis, comorbidity, demo-
graphics, and medication)
• conclusion

Expert Contributors
The chapters are written by both clinicians and researchers, the majority of whom
are licensed psychologists who also engage in publishing university-based research.
Several chapter authors have published books or edited journals related to the focus
of their chapter. Some chapters are authored by just one scholar, while others
 Preface xv

represent collaborative efforts of multiple authors, sometimes including doctoral

students – the next generation of clinicians and researchers. In sum, all of the authors
are champions for the science of clinical psychology.

Target Audience
The goal of this book is to be a handy reference for all therapists, including psycholo-
gists, counselors, social workers, psychiatrists, and professionals in related discip-
lines. Relatedly, it may serve as a primary text for graduate courses in therapy and
counseling. By covering the same broad topics, it works well in tandem with another
book in this series: Pseudoscience in Therapy.

Stephen Hupp
 Acknowledgments

We would like to thank everyone who contributed to the scholarship of ESTs, with
special gratitude in particular to the late Dianne Chambless for leading the way. Sadly,
Steven Jay Lynn died just a few months prior to publication. His contributions to
critical thinking about therapy cannot be overstated, and we are so thankful that he
generously co-authored a chapter in this book. We’re also very thankful to the chapter
authors, who worked diligently to summarize a large body of research in a small
amount of time. Everyone at Cambridge University Press has been extremely helpful
from beginning to end, and we’re especially grateful to Stephen Acerra, who helped
shape all of the books in this series. Also, Rowan Groat always had an answer when
we needed one. As a project manager, Giridharan Gunasekaran expertly guided us
through the final stages of production with considerable help from Helen B. Cooper
(copy-editor), Laheba Alam (content manager), and Carol Bailey (indexer).

xvi
 1
What Is Science-Based Therapy?
David F. Tolin and Stephen Hupp

For much of its history, psychotherapy was not particularly amenable to scientific
inquiry. The psychoanalysis developed by Sigmund Freud (1933/1965), which set the
stage for the development of more modern psychotherapeutic interventions, proposed
several nonfalsifiable constructs, had rather nebulous aims, and was comprised
largely of procedures that were difficult to operationalize (see Paniagua, 1987, for
review; but see also Westen, 1998, for a counterargument). More contemporary
psychodynamic therapies have resolved many (though not all) of these issues, and
the past four decades have witnessed an increase in both the quantity and the quality of
clinical trials of psychodynamic therapy (Thoma et al., 2012). In reaction to the
untestable claims of Freud’s psychoanalysis, science-based approaches began to
emerge, and they focused on examining testable hypotheses.
For better or for worse, the origins of psychoanalysis were in the clinic, not in the
laboratory. As such, psychoanalysis was based on clinical observations of patients,
rather than on scientifically demonstrable processes of behavior, thought, and emo-
tion. The first wave of one science-based approach to therapy development began with
the early behaviorists, who developed their procedures based on laboratory science
with animal and human subjects. Joseph Wolpe (1961) developed systematic desen-
sitization based on earlier studies of classical fear conditioning (Watson & Watson,
1921). Soon thereafter, operant conditioning processes, which had been well estab-
lished in animals and humans (Skinner, 1953), were used to create strategies such as
token economies for patients with chronic mental illness (Ayllon & Azrin, 1968).
These early practices served as proof of concept that laboratory science could be used
to develop strategies to help patients suffering from psychological problems.
Shortly after the development of behavioral interventions, a second wave of this
science-based approach, comprised of cognitive strategies (e.g., Beck, 1976;
Meichenbaum, 1977), led to the development of what is now called cognitive-
behavioral therapy (CBT). Of note, following Freud’s tradition, cognitive interven-
tions came largely from clinical observations, though some research at the time
pointed toward the presence of dysfunctional, conscious cognitive processes in
1
2 David F. Tolin and Stephen Hupp

patients that presumably could be addressed by this new form of therapy (Beck,
1963). Perhaps most importantly, CBT was based on procedures that could be
operationalized and replicated, and targeted outcomes that could be measured, and
it was predicated on purported mechanisms that could be examined scientifically.
Thus, psychotherapy, like other aspects of health care, could readily be studied from
a scientific perspective, as was done in early trials of CBT for depression (e.g.,
Blackburn et al., 1981; Rush et al., 1977). And studied it was, with a massive surge
in research demonstrating the efficacy of CBT for depression, anxiety disorders,
substance use disorders, and a slew of other problems. Under the broad umbrella of
CBT, we are now seeing what has been called a “third wave,” in which some of the
cognitive elements are de-emphasized in favor of strategies such as acceptance and
mindfulness. Dialectical behavioral therapy (Linehan, 1993), acceptance and com-
mitment therapy (Hayes et al., 1999), and mindfulness-based stress reduction (Kabat-
Zinn et al., 1985) are but a few examples of these interventions. Some have called the
idea of a third wave into question, pointing out that in many respects these treatments
resemble the first wave of behavioral therapies (e.g., Hofmann & Asmundson, 2008).
We do wish to be clear, however, that calling a treatment “science-based” does not
necessarily mean that it must be CBT, nor can we safely assume that any new CBT is
automatically based on scientific evidence (for example, see O’Donahue, Snipes, &
Soto, 2016, for a critique of the scientific integrity of “third-wave” approaches). The
developers of any psychological treatment, regardless of its theoretical origins, must
demonstrate that their treatment works, for whom and how well it works, as well as
why it works. This leads us to review several key terms: empirically supported
treatments, evidence-based practice, and science-based therapy (the term we favor
in this book).

Identifying Treatments that Work

Empirically Supported Treatment
The term “empirically supported treatment” (EST) became popular in clinical psych-
ology when the Society of Clinical Psychology (SCP) (Division 12 of the American
Psychological Association) first published criteria for what were initially termed
“empirically validated psychological treatments” (Task Force on Promotion and
Dissemination of Psychological Procedures, 1993) and later termed “empirically
supported psychological treatments” (Chambless & Hollon, 1998; Chambless &
Ollendick, 2001). In this framework, sometimes referred to as the “Chambless
criteria,” a treatment was characterized as being well-established (also called “strong
research support”) if it meets both of these basic criteria:
1. At least two well-done randomized control trials (RCTs) demonstrate the treatment group
has greater symptom reduction than an active comparison group or a placebo group.
 What Is Science-Based Therapy? 3

2. And at least two of these RCTs are conducted by at least two different research teams.

Alternatively, a treatment could be characterized as probably efficacious (also

called “modest research support”) if it meets either of these basic criteria:
1. At least one well-done RCT demonstrates the treatment group has greater symptom
reduction than an active comparison group or a placebo group.
2. Or at least two well-done RCTs demonstrate the treatment group has greater symptom
reduction than a control group. In this case the control group does not need to include an
active comparison group or a placebo. Also, the two RCTs do not need to be from different
research teams for this criterion.

Within this framework, a large number of treatment approaches have been identified
as being well established, and many treatments are also probably efficacious. Most
chapters in this book will identify the current level of support for the treatments being
discussed. For adult patients, the best place to keep up-to-date on the status of ESTs is
the website for the Society of Clinical Psychology (www.psychologicaltreatments.org).
For youth, the website for the Society of Clinical Child and Adolescent Psychology
(www.effectivechildtherapy.org) provides updated information (that resource uses the
term “works well” for well-established treatments and “works” for probably efficacious
treatments). However, it is important to note that changes in the way we identify ESTs
are currently underway.
The initial criteria for ESTs were criticized for setting a low bar for efficacy and
failing to account for mixed findings (Borkovec & Castonguay, 1998; Henry, 1998;
Herbert, 2003), relying solely on symptom reduction over functional outcomes and
quality of life (Cowen, 1991; Hayes, 2004; Seligman, 1995), and failing to account for
variations in the internal validity and degree of research bias in clinical trials
(Luborsky et al., 1999; Wachtel, 2010). In response to these concerns, the Society
of Clinical Psychology updated their EST requirements (Tolin et al., 2015) to include
broad and inclusive reviews of the scientific literature, taking methodological quality
of the study into account and allowing for a multitude of outcomes.
The updated EST requirements suggested by Tolin et al. (2015), sometimes
referred to as the “Tolin criteria,” emphasize the role of high-quality evidence in the
form of systematic reviews comprised of a wide range of well-done studies with
consistent results. Based on this type of evidence, for a treatment to be provided a very
strong recommendation it must meet all of the following criteria:
1. The treatment results in clinically meaningful symptom reduction.
2. The treatment results in clinically meaningful functional outcome improvement.
3. Symptom reduction and/or functional outcome improvement last at least three months once
the treatment has ended.
4. At least one well-done study demonstrates a clinically meaningful effect in a nonresearch
setting.
4 David F. Tolin and Stephen Hupp

Alternatively, a treatment can be given a strong recommendation (as opposed to the

aforementioned “very strong” recommendation) based on moderate- to high-quality
evidence from systematic reviews and at least one of the following criteria:
1. The treatment results in clinically meaningful symptom reduction.
2. And/or the treatment results in clinically meaningful functional outcome improvement.

Overall, these updated criteria raise the bar for providing a recommendation about
which treatments have adequate research support. Rather than relying on only two
(possibly cherry-picked) studies, the revised criteria now require that all of the
available evidence on a given treatment’s effects be taken into account, not only
those studies that are favorable to the treatment. Rather than relying on posttreatment
symptom reduction alone, the revised criteria now highlight the importance of
functional improvement and longer-term outcomes. And, finally, the effectiveness
of a therapy in a “front-line” clinical setting is considered. To date, only a handful of
treatments have been evaluated within this framework (see the Postscript for an
overall summary).

Evidence-Based Practice
Work on ESTs was an important catalyst for an increased emphasis on evidence-
based practice (EBP). EBP is a broad template of activities that include assess-
ment, case formulation, relationship factors, and treatment decisions that are
hoped to assist the clinician to achieve the best possible outcome. In 2006,
a Presidential Task Force of the American Psychological Association (APA
Presidential Task Force on Evidence-Based Practice, 2006) adapted the Institute
of Medicine’s (2001) definition of evidence-based medicine, defining EBP as
practice that integrates three sources of information: patient characteristics, clin-
ical expertise, and the best available research evidence. It is unclear as to whether
EBP represents a step forward or a step backward from the EST movement. The
emphasis not only on science but also on patient characteristics and clinical
expertise seems intuitively logical, and it’s hard to argue that these other factors
shouldn’t be taken into consideration. On the other hand, it is not clear, in this
“three-legged stool” model, whether each leg of the stool should be weighted
equally. What should a clinician do, for example, when the best scientific evidence
points to exposure with response prevention for obsessive-compulsive disorder,
yet the clinician’s patient differs from the RCT participants in important ways and
the clinician’s expertise is in another aspect of therapy? Should the scientific
findings be thrown out? One possible solution is to give priority to scientific
research, with clinician expertise and patient characteristics serving as “filters”
through which the research must pass (Tolin, 2012). However, that has not been
codified into the EBP definition used by the American Psychological Association
 What Is Science-Based Therapy? 5

(APA), and at present the term “evidence-based” has been used (and misused) so
often that we fear its meaning has been degraded.

Science-Based Therapy
In this book, we’re going to use the term “science-based therapy,” which overlaps
with the Chambless and Tolin criteria for ESTs and the more recent conceptualization
of EBP. Although the Chambless criteria were silent on the ingredients of treatment
(that is, the question at hand was simply whether or not a treatment worked), the Tolin
criteria did note that the ingredients and mechanisms of therapy were also important:
The Task Force may take into account the purported mechanism or active ingredient(s) of
treatment, and may upgrade or downgrade the recommendation based on the quality of
evidence supporting that mechanism or ingredient(s). It is conceptually difficult to standardize
this consideration into the criteria, as admittedly the mechanisms of many efficacious treat-
ments are unclear. However, to the extent that a given treatment is based on a specific
purported mechanism, or relies strongly on a particular treatment ingredient, the [reviewers]
can and should consider whether those assertions are supported.
(Tolin et al., 2015, p. 331)

This added emphasis on not only whether a treatment works, but also why it works,
represented a step forward in the EST movement, pointing toward what would later be
termed “science-based practice.” That term, proposed by Lilienfeld et al. (2018),
denotes that “treatment outcome data are considered along with broader research
evidence bearing on the plausibility of the treatment’s theoretical rationale when
evaluating an intervention’s scientific status” (p. 44; italics added). Thus, science-
based practice extends the idea of ESTs by focusing not just on outcomes but also on
whether the treatment is based on mechanisms of change that are scientifically
credible. Here, in addition to RCTs comparing a treatment to a control condition,
dismantling studies become critical, in which elements of the treatment are systemat-
ically withdrawn to test whether those elements are indeed responsible for the clinical
outcomes. Rosen and Davison (2003) illustrated the idea with a tongue-in-cheek
description of “purple hat therapy,” in which a practitioner uses well-established
CBT principles while the patient also wears a purple hat, and then mistakenly
attributes the patient’s successful outcome to the purple hat, later packaging and
selling this “new” therapy. In case you think this was just for laughs, consider for
a moment the promulgation of what have been called “energy” therapies, in which
noncredible (in our opinion) elements such as acupressure point tapping have been
added to traditional elements of CBT, and are currently being marketed as “evidence-
based” new treatments.
We had purple hat therapy firmly in mind as we compiled this book. We want you,
the reader, to understand not only what treatments work for given psychological
problems, but also why they work. Hence, we strove to eliminate therapeutic “filler.”
6 David F. Tolin and Stephen Hupp

Box 1.1 Pseudoscience-Based Therapy

Many of the components used in the so-called energy therapies can be characterized as
pseudoscience. That is, saying that acupressure point tapping is evidence-based, when
in fact no rigorous research supports this claim, represents the dissemination of false
information under the cover of scientific-sounding language. Energy therapies are
commonly used for anxiety- and trauma-based disorders, but pseudoscience abounds
for just about every other type of disorder as well. Some of the more outrageous
treatments include bee-sting therapy for depressive disorders, dolphin-assisted therapy
for neurodevelopmental disorders, and homeopathy for just about every mental health
affliction that ails you. In fact, there are so many dubious therapeutic approaches that
two books in this series focus solely on the topic. The book Pseudoscience in Therapy
(Hupp & Santa Maria, 2019) critiques dubious treatments for adults, and the clinical
topics are covered in the same order they are covered in this book, making the two
books great companions. Further, the book Pseudoscience in Child and Adolescent
Psychotherapy (Hupp, 2019) critiques dubious treatments for youth.

We challenged our chapter authors to name the specific and credible ingredients of
effective treatments, and to produce evidence showing why those ingredients are
effective. Of course, we recognize that not every ingredient in therapy will have solid
evidence from dismantling research. But, in the absence of such evidence, we should
at least expect that there will be a scientific reason why these ingredients should be
credible. That is, how well do these therapy ingredients match up with what is
currently known about the brain and behavior? Elements such as acupressure tapping
are disconnected from current scientific understanding of psychological processes,
and as such lack credibility (let alone evidence). To be sure, we aren’t saying that such
things can’t work, but we should remain skeptical until we see compelling evidence
that they do work. And when an ingredient is credible yet unsupported, that should
serve as a call for researchers to investigate.

Conclusion
Over the last few decades, the Society for Clinical Psychology has led the way in
conceptualizing and identifying ESTs. Most, but not all, of these treatments tend to be
from the behavioral and cognitive traditions, though it need not be so. The conceptu-
alization of ESTs is continuing to evolve, and previously identified ESTs are just now
starting to get reassessed using the newer science-based criteria that place a greater
emphasis on systematic reviews, functional outcomes, lasting effects, and credible
active ingredients.
We would argue that science-based therapy is not merely an academic issue, but
also an ethical issue. That is, the ethical practice of psychological therapy is based on
 What Is Science-Based Therapy? 7

science. Patients receiving any form of health care have a right to expect that their
provider will be aware of, understand, and apply the best available science to their
condition. Behavioral health should be no different. The American Psychological
Association’s ethical guidelines state “Psychologists’ work is based upon established
scientific and professional knowledge of the discipline” (American Psychological
Association, 2017, p. 5), though we note that the ethics code is silent on what
constitutes “scientific and professional knowledge.” We would take this a step further
by suggesting that our patients have the right not only to receive treatments based on
the best available science, but also to receive accurate information about their condi-
tion, why it has occurred, and what will help. Here, we suggest that an ethical
practitioner appropriately applies knowledge from the science of psychology to
explain the patient’s condition and its resolution (see Sechrest & Smith, 1994).
Accordingly, explanations based on empirically unsupported mechanisms such as
energy meridians, chakras, eye movements, and similar features are not only scientif-
ically unsound but also ethically unjustifiable.
In this book, you’ll hear from leading clinician-scientists about their areas of
expertise. One emphasis will be on what works, both for adult patients and, to
a lesser extent, for their younger counterparts (other books in this series place
a greater emphasis on children and adolescents). Each author will describe the psycho-
logical treatments known to be efficacious for a given condition, and will provide the
scientific justification for how we know those treatments are efficacious. This aim will
help you answer the basic question of “what treatment should be used with this
patient?” But the chapters don’t stop there. In keeping with the principle of science-
based therapy, we have asked each author to also describe the credible mechanisms of
change within and across ESTs. That is, rather than solely asking what treatment
“package” works, we also wanted to clarify which mechanisms of change have
empirical support or are at least scientifically plausible. In our opinion, a good therapist
needs to be more like a chef than a cook – that is, able not only to follow a recipe (e.g.,
a manualized treatment approach), but also to use a case formulation approach to build
a patient-focused treatment from the ground up, based on the best available science and
the particular characteristics of the patient. You’ll see in these chapters that even within
a given therapeutic framework, there’s a fair amount of wiggle room. So a good “chef”
therapist will strive to maximize the elements of treatment that lead to the largest
effects, rather than just sticking to a manual.
We also want you to see where the gaps are in our current knowledge. That is, what
don’t we know? Our hope is that clinicians, researchers, and clinician-researchers will
find this book to be a useful guide toward further inquiry about what works and why.
We recognize that the domain of science-based therapy is very much a work in
progress, so nothing in this book should be taken as the last word on the topic.
Science is constantly adding new information and new perspectives, and we hope to
be able to update this book in the future with that new knowledge.
8 David F. Tolin and Stephen Hupp

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 2
Depressive Disorders
John R. McQuaid and Alfiee Breland-Noble

The Diagnostic and Statistical Manual for Mental Disorders-5th Edition, Text
Revision (DSM-5-TR; American Psychiatric Association, 2022) defines major
depressive disorder (MDD) as a period of at least two weeks in which the
person experiences five or more symptoms of depression nearly every day, and
at least one of the symptoms is either depressed mood or loss of interest/
pleasure. To meet the criteria for MDD, the symptoms must cause clinically
significant distress or impairment of functioning; cannot be attributable to
substance use, a medical condition, or better attributed to another disorder;
and the patient must never have had a manic or hypomanic episode. Diagnostic
specifiers include anxious distress, atypical features, mood congruent psychotic
features, mood incongruent psychotic features, catatonia, peripartum onset, and
seasonal pattern.
Persistent depressive disorder (PDD) is a chronic variation of a depressive disorder
that can be less intense, with fewer symptoms, but of longer duration (at least two
years in adults). The symptoms must cause clinically significant distress or impair-
ment of functioning; must not be attributable to substance use, a medical condition, or
better attributed to another disorder; and the patient has never had a manic or
hypomanic episode. This chapter focuses primarily on MDD, for which there is
a more extensive literature base.
Approximately 21% of the US population experiences a depressive episode in
their lifetime, with an estimated 10% having an episode in any twelve-month
period (Hasin et al., 2018). Due to the prevalence and severity of impairment,
clinical depression generates the highest disease burden of any mental health
disorder as measured in disability-adjusted life years (DALYs; a measure of
years of life lost due to premature mortality, disability, or time lived in states of
less than full health) and is the sixth highest contributor of DALYs of any cause
for adults in 2019, up from eighth in 1990 (Global Burden of Disease Study,
2019). This impact highlights the importance of providing effective treatments for
depression.
11
12 John R. McQuaid and Alfiee Breland-Noble

Etiology and Theoretical Underpinnings of Treatment

A recent literature review identified a broad range of factors associated with
depression risk (Remes et al., 2021). Some of the factors have been long recognized,
including genetic vulnerability, psychological and traumatic stress, cognitive fac-
tors, psychological vulnerability (e.g., both beliefs and thinking processes such as
rumination that increase risk of depression), social determinants (including social
support deficits, systematic biases based on individual characteristics such as race or
gender, lack of access to resources), and gene–environment interactions. More
recently identified risk factors include vulnerabilities involving the microbiome
and inflammation. However, different treatment models focus on specific etio-
logical mechanisms.
Behavioral theorists argue for a learning model of depression based on lack of
reinforcement (e.g., engaging in behaviors that lead to positive affect and increase the
likelihood of future behavior). Individuals with depression are thought to either have
limited opportunity to engage in rewarding behaviors (e.g., being unable to find
employment, losing a positive relationship) or to have experiences that are not
reinforcing (e.g., being rejected in a relationship or fired from a job). These factors
lead to withdrawal from or avoidance of possible reinforcing experiences. This
reduction in reinforcement could lead to depressive symptoms, which in turn reduce
the likelihood of engaging in reinforcing experiences, leading to a downward cycle of
increased depression and decreased rewarding behavior and engagement in social
networks which are protective factors against depression (Santini et al., 2015). They
propose that treatments helping patients identify and engage in rewarding activities
are key to countering the deprivation in reinforcement associated with depressive
illness (Lewinsohn & Graf, 1973).
Cognitive theory posits that belief systems interact with life events to create risk
for depression. They argue that certain cognitive schema (defined as “negatively
toned representations of self-referent knowledge and information that guide
appraisal and interact with information to influence selective attention, memory
search, and cognitions”; Scher et al., 2005, p. 489) increase hopelessness and
negative self-image, and reduce likelihood of engaging in healthy behavior.
Examples of such schema include identifying one’s value as arising from one’s
productivity (leading to vulnerability if out of work) or that one must be loved to
have value (leading to depression in the face of rejection). The role of cognitive
processes including schema as predictors of depression onset, as well as the
efficacy of treatments designed to modify these processes, is well established
(Scher et al., 2005). Therapies that incorporate cognitive theory teach patients to
identify and change their thinking patterns, to engage in activities that help test and
challenge unhelpful beliefs, and to focus on the present rather than delving deeply
into past experiences (Beck et al., 1979).
 Depressive Disorders 13

“Third wave” approaches are derived from behavioral and cognitive theories and
incorporate mindful observation, attentional control, distress tolerance, and accept-
ance of emotional experience. These models highlight that depressive episodes, and
particularly recurrent or chronic depression, are associated with difficulty recognizing
that thoughts may not be true or helpful and that individuals with depression often
engage in ineffective coping strategies (e.g., attempts to avoid emotional experience;
Hayes et al., 2001). In contrast to traditional cognitive and behavioral models, third-
wave approaches focus on learning to observe and experience emotions and cogni-
tions, particularly unpleasant or painful ones, rather than changing emotions. The
intent of intervention is to be able to tolerate a broad range of experiences and
continue to act on core beliefs and values to achieve goals rather than having
depressive symptoms guide behavior.

Brief Overview of Treatments

Current clinical practice guidelines for the treatment of depressive disorders identify
several psychotherapies as first-line treatments. The American Psychological
Association clinical practice guidelines identified limited options with sufficient
research support for either adolescents (only cognitive-behavioral therapy [CBT])
or older adults (CBT or interpersonal psychotherapy [IPT]). However, for adults, they
identified a range of treatment options, including acceptance and commitment therapy
(ACT), behavioral activation/behavior therapy (BA/BT), CBT, IPT, and short-term
psychodynamic psychotherapy (STPP; American Psychological Association, 2019).
Similarly, the Department of Veterans Affairs and Department of Defense CPG
recommended a similar list of psychotherapies for adults, including ACT, BA/BT,
CBT, IPT, mindfulness-based cognitive therapy (MBCT), problem-solving therapy
(PST), and STPP (McQuaid et al., 2022). The United Kingdom’s review process,
NICE, recommends (depending on depression severity) BA/BT, CBT, counseling,
IPT, mindfulness interventions such as MBCT, and STPP (NICE, 2022). Division 12
of the American Psychological Association (APA) has also characterized most of
these variations of behavioral and cognitive therapies as being well-established based
on the original criteria for empirically supported treatments (Chambless & Hollon,
1998). See the Postscript of this book for a more specific list. These conclusions (that
there are multiple psychotherapeutic approaches that are efficacious and there is
limited evidence of differences between them) are supported by multiple systematic
reviews and meta-analyses. For example, a meta-analysis of 409 trials examining
CBT found a moderate to large effect size (g = 0.60 to 0.79 depending on risk of bias
of the studies included) when compared to control conditions. When compared to
other psychotherapies, including BA/BT, IPT, PST, third-wave, and other models,
CBT had a slight significant advantage (g = 0.06) that became nonsignificant in
most sensitivity analyses, suggesting comparable effects across treatment models
14 John R. McQuaid and Alfiee Breland-Noble

(Cuijpers et al., 2023a). An earlier meta-analysis out of the same group with 228
studies, including 18 studies that included a comparison between two psy-
chotherapies, found no difference in outcome between psychotherapies (Cuijpers
et al., 2021).

Credible Components of Treatments

While there are a number of efficacious and effective treatment options available for
depression, the evidence for the contribution of the specific treatment components that
comprise these interventions is more limited. The most common tools for testing
specific aspects of treatments are dismantling studies which compare key components
of psychotherapies.
There are significant similarities undergirding current science-backed psychothera-
peutic treatments including BA/BT, CT/CBT, and PST, and to a lesser extent IPT and
SSPT. The common components of these theories include a biophysical and behav-
ioral model of psychotherapy with demonstrated effectiveness in White populations.
Less knowledge exists on the effectiveness of these treatments when considering
sociocultural factors such as race, culture, and ethnicity. For example, each in some
way focuses on more individual root causes for depression such as genetic precursors,
interpersonal relationships, the development of negative behaviors, negative thought
patterns, and negative conceptualizations of life events (Stark et al., 2000), rather than
environmental or systemic factors that may disproportionately affect people of color
or other marginalized populations.
Common components across treatment models that are held up as critical
factors and levers of change in science-backed depression treatments are influ-
enced in part by their testing in randomized controlled trials and grounding in
manualized approaches. Components thought to underlie depression treatment
effectiveness include “a) therapeutic relationship, b) activation of resources, c)
actualization of the patient’s problems, d) motivational clarification, and e) (active
help for) problem solving” (Woike et al., 2019, p. 1), while established mediators
include change in dysfunctional attitudes, negative “automatic” thoughts, mind-
fulness and worry skills, and rumination-mediated change in outcomes (e.g.,
depression symptoms).
Overall, theories undergirding the most established psychotherapeutic treat-
ments for depression are grounded in a biopsychosocial model which suggests
that strong rapport between provider and patient is crucial, along with a focus on
individual behavior changes as the primary factors for improving depression
outcomes. A consideration for future development of effective treatments is to
incorporate strategies that address environmental/social/systemic factors (e.g.,
poverty, bias, disparities in access to resources) that exacerbate mental health
concerns.
 Depressive Disorders 15

Behavioral Activation
In behavioral activation, patients are encouraged to hold a present orientation while
engaging in collaborative efforts with providers. The label of “behavioral activation”
was developed for a dismantling study that found no differences between three
treatment conditions: behavioral activation alone; behavioral activation plus cogni-
tive restructuring; and behavioral activation, cognitive restructuring, and schema
change (Jacobson et al., 1996). Key targets of behavioral activation include increasing
access to positive reinforcement of healthy behaviors, and working through barriers to
utilizing the skills of activation (Uphoff et al., 2020). Behavioral activation also
includes activity scheduling, the development of social skills to increase access to
and success in social interactions, and mood monitoring linked to daily behaviors.
Behavioral activation is used both as a component of depression treatment (mainly in
CBT) and as a stand-alone treatment for depressive illness.
Multiple studies of behavioral activation have demonstrated its efficacy, though
little of this data is based on racially/ethnically diverse samples (Mazzucchelli et al.,
2009). As a result, while there is evidence that behavioral activation works for White
populations, it remains unclear how generalizable behavioral activation approaches
are for people of color across the life span. This is particularly concerning given the
individual orientation of the approach with little consideration of systemic issues
(e.g., environmental risks, systematic bias, disparities in access to resources) that
disproportionately impact communities of color. This same point could be made for
all of the components discussed in this chapter, so rather than repeating the point we’ll
discuss the value of cultural humility in Box 2.1.

Box 2.1 Cultural Humility

Even when providers make cultural adaptations to psychotherapeutic approaches,

including cognitive-behavioral approaches, people of color demonstrate high attrition
rates in treatment when compared to their White peers. Therefore, enhancements are
necessary at the treatment engagement level to even allow diverse populations to
receive adequate “doses” of the types of treatments described herein, to allow for the
possibility of benefit from the critical components of cognitive-behavioral approaches
(Breland-Noble & The AAKOMA Project, 2022; Breland-Noble et al., 2016).
When quantifying the various benefits of psychotherapies, researchers seek to
better understand both how and why various approaches work. This research involves
examining factors such as the utility of treatments for different types of illnesses,
frequency and intensity of treatment needed to generate positive outcomes, changes in
illness symptomatology over time, and role of patient–provider alliance. While data are
available to help the field better understand these factors, two factors that continue to
be absent from the literature are individual factors and social determinants of health.
Historically, research on individual factors has focused heavily on certain patient
16 John R. McQuaid and Alfiee Breland-Noble

characteristics (e.g., illness symptomatology and severity of symptoms), factors

impacting attrition, and patient–provider alliance (Flückiger et al., 2012; Luborsky
et al.,1971). Key factors studied regarding provider characteristics include provider level
of training and fidelity to treatment approaches (Diebold et al., 2020; Mowbray et al.,
2003). Research on patient–provider alliance suggests that a patient’s positive regard
for the therapist as someone who demonstrates support for them, level of agreement
between patient and therapist on the goals of treatment, and agreement between
therapist and patient on the effectiveness of approaches to achieving the goals set are
all critical components necessary for positive outcomes (Miller & Moyers, 2021).
Missing from these factors related to outcomes are provider cultural competence,
which has been described as “a constellation of the right personal characteristics
(awareness, knowledge, and skills) that a counselor or therapist should have” (Sue
et al., 2009, p. 4), individual patient demographic characteristics, and their impact on
outcomes and social determinants of health.
An emerging body of literature has specified the ways in which cultural competence
and attention to cultural differences in treatment enhance therapeutic alliance and
clinical outcomes in psychotherapy, including depressive illness (Breland-Noble &
Miranda, 2017; van Loon et al., 2013). Specifically, a combination of creating
a welcoming space, allowing the patient to feel understood, recognizing cultural
differences, and creating a sense of familiarity have profound positive impacts upon
which patients can then build a repertoire of tools for their self-care between sessions.
Regarding patient demographics, the field has historically failed to power treatment
studies to allow for the examination of individual differences (e.g., race, LGBTQ identity,
socioeconomic status) in depression treatment outcomes.
Most psychotherapeutic approaches widely promoted today do not have evidence
of wide generalizability across diverse populations (e.g., race, gender, LGBTQ identity,
and persons with disabilities). Therefore, we need to review the relationships among
these key aspects of identity (including identity-based trauma exposure) and reflect on
their relationship to depression treatment and its components (including help-seeking
behaviors and treatment engagement).
Mental health disparities and equity scholars have examined key components
important for improved outcomes in depression treatment. The majority of this
literature points to possible efficacy and effectiveness, but too few treatments have
been tested with samples adequately powered to establish scientific efficacy or
effectiveness across diverse groups (American Psychological Association, 2019). Two
meta-analyses of evidence-based mental health treatments (including those for
depression) for youth of color found only modest support, reflecting possibly efficacious
or probably efficacious outcomes (Huey & Polo, 2008). The same is true for adults of
color across the lifespan, as recently examined by the American Psychological
Association’s depression guideline panel (American Psychological Association, 2019).
 Depressive Disorders 17

Cognitive Restructuring
An extensive body of literature has established that depression is associated with
a number of cognitive variables, referred to as “cognitive vulnerabilities,” that are
associated with increased risk for depression onset, relapse, and recurrence (Scher
et al., 2005). As noted, a cognitive schema is a style of thinking that when present in
the context of a stressor is likely to lead to interpretations of the experience that
increased the likelihood of a depressive episode. An example of a cognitive schema
interacting with a stressor might be a person who believes “I need to be productive to
be worthwhile” and who, after losing a job, determines they have no value and
develops feelings of worthlessness and hopelessness.
The components of CBT are designed to address cognitive schemas and change the
thoughts and behaviors that arise from them. Patients work with providers to recognize
faulty thinking and behaviors, to better understand their learning history, and to develop
skills to change beliefs and behaviors. Typical tools used to facilitate learning in CBT
include learning to identify unhelpful thoughts and behaviors, conducting behavioral
experiments to test beliefs and alternative behaviors, using role-play to practice new
skills, and identification and modification of cognitive schema from which automatic
thoughts and problematic behaviors arise. CBT has the largest body of supporting
literature of any psychotherapy, with multiple studies across the age span (primarily
in White western samples) finding it to be effective with these populations (American
Psychological Association, 2019; Gould et al., 2012; Weersing et al., 2016).

Problem Solving
Problem solving therapy is a model rooted in cognitive and behavioral principles
guided by the theory that psychopathology is best understood as an individual’s use of
maladaptive coping skills (Nezu, 1986; Nezu & Perri, 1989). The provider and patient
collaborate to identify and illuminate a presenting problem (or set of problems) and
then work on providing the patient with tools to develop and practice adaptive and
positive coping to address the problem. In doing so, the patient develops a greater
sense of self-efficacy, reduces the negative impacts of the presenting issue, and
develops confidence in their ability to address similar problems in the future. The
five core components of problem solving include a positive problem orientation (i.e.,
the ability to evaluate a problem with the belief that is it solvable and a normal part of
life), problem definition and formulation, generation of alternatives, decision-making,
and solution implementation and verification. Multiple meta-analyses show the lar-
gest effect sizes when all five components are incorporated within the course of
treatment (Bell & D’Zurilla, 2009). Problem solving is considered effective and
comparable to other psychotherapies for the treatment of depression (with modest
effect sizes; Cuijpers et al., 2018).
18 John R. McQuaid and Alfiee Breland-Noble

Mindfulness
The development of MBCT reflects a model that epitomizes the use of an a priori
evidence-based theory to identify an intervention based on hypothesized mechanisms
of the disorder and evaluated in relation not only to outcomes but to the hypothesized
mechanism. Originally developed as an intervention for the prevention of relapse in
individuals with a history of depression, MBCT is predicated on evidence that
individuals with a history of depression have cognitive vulnerabilities that can be
activated by stress and increase the likelihood of depressive episodes. The developers
of MBCT posited that the techniques of mindfulness, including nonjudgmental
observation of internal experiences, would allow individuals to respond to experi-
ences in a manner that was not driven by the underlying cognitive vulnerability and
would in fact potentially modify the vulnerabilities to reduce the likelihood of future
depressive episodes. In a series of key studies, the authors found that MBCT was
associated with reduced risk of depression (Teasdale et al., 2000) and reduced
distorted thinking indicative of a cognitive vulnerability (Teasdale et al., 2022).
Further studies have demonstrated that MBCT is effective not only for preventing
recurrence for those with a history of depression but also for treating individuals
experiencing a current depressive episode (Strauss et al., 2014).

Acceptance and Commitment

The interventions in ACT derive from relational frame theory, which focuses on the
nature of language (including thoughts) having emotional and representative meaning
that is learned by association with the items to which the language is connected
(Hayes et al., 2001). Because of the strength of these associations, thoughts can create
emotional experiences that feel like the events with which they are associated (e.g.,
thinking of being criticized by a loved one) and these experiences can contribute to
depression. The treatment therefore emphasizes developing the ability to observe
one’s internal experience, including thoughts and emotions, without letting it deter-
mine one’s actions but learning instead to act based on values and goals even in the
context of painful emotions. Components of ACT include a number of techniques
designed to address six core processes: acceptance (particularly of negative experi-
ence); cognitive defusion (i.e., recognizing a thought as being just a statement in one’s
mind, like reading a sentence, rather than something that has inherent truth and
power); being present; understanding the self as context (i.e., learning to connect
with a stable sense of self from which to observe changing experiences such as
emotions and thoughts); identifying values; and committing to act on values. While
the specific components of ACT have not been evaluated for efficacy, the overall
model led to significant improvement for treatment of depression and was not
significantly different from CBT (Ost, 2014).
 Depressive Disorders 19

Addressing Interpersonal Targets

The IPT model draws upon attachment and interpersonal theories, which propose that
early loss leads to increased vulnerability to depression and that negative life events,
particularly in relational domains, can provoke depressive episodes. The developers
designed an intervention that targets four domains: role transition (e.g., moving from
employment to retirement); role conflict (e.g., disagreeing with a spouse regarding
who has what responsibilities managing a household); loss (specifically loss of
a loved one); and interpersonal skills deficits (Klerman et al., 1984). Each of these
dimensions are associated with stressors that have been demonstrated to increase risk
for depression (Brown & Harris, 1989). The IPT approach is a structured treatment
that is administered over a set number of sessions. Interventions include an interper-
sonal inventory to identify the target domain for treatment and create an interpersonal
formulation, conducting a communication analysis to identify targets for coaching
and role-play, exploration of problems and facilitating the client in identifying their
goals and the approach they would like to take to achieve them, facilitating grief and
mourning when some goals cannot be achieved, and use of the termination/graduation
process to facilitate a healthy role transition.

Comparing Components
While it is well established that psychotherapies in general are more effective than no
treatment in reducing depressive symptoms, the efficacy of specific components has
received only limited attention, and the studies, with a few exceptions, focus on CBT.
An early example was a trial of CBT for depression that examined three separate
conditions: cognitive restructuring, behavioral activation, and assertive skills training
(Zeiss et al., 1979). The authors found that all three conditions led to decreases in
depressive symptoms and improvements in target behaviors, including interpersonal
skills, cognitive style, and pleasant activities. However, there was no evidence that
effects were specific to the target in question and there were no differences among
conditions on the improvements in any domain. The authors argued that the improve-
ment in symptoms reflected an increase in self-efficacy in general, regardless of the
domain in which it was occurring.
The study of behavioral activation compared to two cognitive therapy conditions
cited earlier also found no differences in outcomes (Jacobson et al., 1996). The
authors later developed behavioral activation as a separate intervention that is now
considered evidence-based in its own right by the VA/DoD and APA guidelines.
Additional studies of specific components of effective treatments for depression are
limited. A meta-analysis of dismantling or component studies found a total of fifteen
trials that met the inclusion criteria (Cuijpers et al., 2017). Thirteen were trials of CBT
(including MBCT and behavioral activation/behavior therapy) either adding or
20 John R. McQuaid and Alfiee Breland-Noble

removing a component, one was a dismantling trial of IPT, and one was a dismantling
trial of full self-control therapy, an intervention which currently is not included as an
evidence-based practice.
The key conclusion was that all but one study did not have sufficient power to
detect meaningful differences among different treatments. The one study exception
that had adequate power found a significant benefit of the addition of emotion
regulation skills to CBT on an inpatient unit (Berking et al., 2013). In addition, one
other trial found a benefit from the addition of a component (hypnosis added to CBT;
Alladin & Alibhai, 2007) and two found that the full intervention of PST was superior
to partial or abbreviated PST (Nezu, 1986; Nezu & Perri, 1989).
In addition, there is evidence that a large portion of change in psychotherapy for
depression is not associated with specific treatment components but rather with
general factors shared across interventions. A meta-analysis found that only 17% of
variance in treatment outcome for depression was attributable to treatment specific
factors, while nearly half (49.6%) was attributable to nonspecific factors and 33% was
attributable to natural recovery (Cuijpers et al., 2012). While there are several limita-
tions to this conclusion due to constraints of meta-analytic designs (Cuijpers et al.,
2018), it highlights the challenge of understanding the role of specific theoretically
derived interventions in the treatment of depression.

Approaches for Youth

Depression in children and adolescents is a significant concern, with rates rising
from 2% in childhood to as high as 20% by age eighteen (Bose & Pettit, 2018).
Depression in youth may manifest with irritability rather than sadness. This can
present as increased activity (i.e., engaging in nondirective behaviors with increas-
ing frequency and consistency), aggressiveness, or antisocial behaviors. A clinical
assessment is critical to accurately identify the diagnosis and appropriate treatment
options.
There is a more limited literature regarding treatment of depression in youth, and
particularly young children, when compared to adults. The APA depression guideline
panel found insufficient evidence to make recommendations for treatment in children
(American Psychological Association, 2019). For adolescents, two interventions had
sufficient research to support a recommendation: CBT and IPT. Both interventions
incorporate components of the adult versions of the interventions. Of note, one
version of CBT, the Coping with Depression Course, was designed specifically for
a group format and as a treatment to prevent depression in vulnerable adolescents
(Clarke et al., 1995). In considering treatment of youth and young adults, there is less
evidence about what treatments are effective for stigmatized youth, including youth of
color or LGBTQ youth, and what data are available suggest they are less likely to
receive treatment than their White counterparts (Price & Hollinsaid, 2022) and
 Depressive Disorders 21

less likely to benefit from it when they do, particularly in high-stigma environments
(e.g., states with more racist attitudes reported or more restrictive policies regarding
LGBTQ people; Price & Hollinsaid, 2022). These findings highlight the need for
increased outreach and engagement, particularly given recent increases in suicidal
behavior among youth of diverse racial/ethnic backgrounds (Charpignon et al., 2022).

Other Variables Influencing Treatment

Assessment and Diagnosis
This chapter has focused on MDD in part because it is the most researched mood
disorder. However, there is significant variability within MDD, as well as between
MDD and other mood disorders, that influences treatment considerations. For
patients with severe depression who are not responsive to initial treatment or with
a history of multiple depressive episodes, most guidelines recommend combining
psychotherapy with pharmacotherapy (American Psychological Association, 2019),
and recent meta-analyses indicate that combined treatment is more effective for
moderate depression as well (Cuijpers et al., 2023b). For recurrent depression,
MBCT was specifically created to treat it, and there is evidence that it both is an
effective intervention and reduces risk of relapse or recurrence (McCartney et al.,
2021). However, in a comparison with CBT there was no difference in preventing
relapse (Farb et al., 2018). Third-wave models have in general been advocated for
persistent depressive disorder, and while there is some evidence that MBCT,
cognitive-behavioral analysis system of psychotherapy (CBASP, a CBT model
that includes a structured interpersonal focus), long-term psychoanalytic psycho-
therapy, and IPT plus medication may be particularly effective for PDD (McPherson
& Senra, 2022), the data are based on limited number of studies (generally 1 or 2 per
model) and replication is required.
Once a diagnosis is established and treatment is initiated, a key effective treatment
component is measurement-based care. The use of regular symptom assessment and
incorporation of it into the planning and implementation of treatment has been
demonstrated to improve outcomes across treatments, though additional research is
indicated for underserved populations (Guo et al., 2015). While use of measurement-
based care is an integral component of cognitive, behavioral, and third-wave models,
it has been incorporated effectively across many approaches to treatment to increase
the effectiveness of the approach.

Comorbidity
Depression is comorbid with a broad range of other disorders, including anxiety
disorders, personality disorders, and substance use disorders (Richards &
O’Hara, 2014). In addition, depression is associated with many medical
22 John R. McQuaid and Alfiee Breland-Noble

disorders, including cancer, diabetes, heart disease, HIV/AIDS, multiple scler-

osis, and pain associated with multiple causes. Depression can further exacerbate
health problems such as diabetes and heart disease (Katon, 2003). Recently,
researchers have begun to link exposure to racism and discrimination to depres-
sive illness and disparate mental health outcomes (Williams, 2018). These
comorbidities can complicate effective treatment and highlight the need to for
providers to be thorough in assessing contributing factors. Currently, most
research on effective treatments does not address comorbidities so clinicians
need to draw on both the best information available as well as clinical judgment
in developing treatment plans.

Demographics
There is limited data on the effectiveness of any approaches for the treatment of
depression in people of color, people who identify as LGBTQ, those with disabilities,
and people whose identities include intersections among these identities. Of the
available evidence, the best assessments suggest CBT for depression as probably or
possibly efficacious with people of color (e.g., Black and Latinx youth) (Pina et al.,
2019). The American Psychological Association’s clinical practice guidelines for
depression note that
the limitations of the literature highlighted the need for funding agencies and investigators to
explicitly address differences, in particular, culture, ethnicity, sex, sexual minority, gender
identity, disability, nationality of origin, generation status, race, socioeconomic status, and
others, as well as the intersection of these variables, which can further influence treatment.
These are areas that could contribute to the experience and treatment of depression but for
which the panel did not have an adequate literature to address.
(APA, 2019, pp. 22–23)

Little has changed in the years since the panel wrote that statement.
There are differences between patient populations both in frequency of
depressive disorders, access to care, and response to treatment. Women consist-
ently report twice the rate of depression that men do, and individuals under age
sixty-five report higher rates than do those over sixty-five (Hasin et al., 2018).
While White and Native American people are at higher risk than Black, Latinx,
and Asian American populations, recent research has identified links between
racism-based trauma and depressive illness (a heretofore understudied phenom-
enon), suggesting a need to better explore depression and other mental health
disorders in these populations (Breland-Noble et al., 2016; Torres & Ong, 2010).
In addition, Black and Latinx populations with depressive disorders are less
likely to receive treatment compared to White populations (McGregors et al.,
2020), and data regarding treatment efficacy and effectiveness are very limited
for these populations.
 Depressive Disorders 23

Medication
In addition to the psychotherapies that are efficacious and effective for treatment of
depression, there is an extensive list of effective medications. While current guide-
lines recommend either an antidepressant medication or an evidence-based psycho-
therapy for uncomplicated major depression, they recommend combined treatment
(medication and psychotherapy) for complicated, treatment nonresponsive, severe, or
chronic depression (American Psychological Association, 2019; McQuaid et al.,
2022). While evidence does demonstrate that combined treatment can improve
treatment outcomes (Cuijpers et al., 2023b), it is not clear if the benefits of combined
treatment are additive or interactive. It is possible that medication can reduce symp-
toms that interfere with engagement in psychotherapy, leading to additional benefit.
Alternately, psychotherapy that incorporates strategies to improve adherence to
medication may lead to better outcomes, in part due to increased effectiveness of
the medication. Future research is needed to determine how to best combine psycho-
therapy and pharmacotherapy. One developing area where there is a great deal of
interest is in psychedelic-assisted psychotherapy. Recent theories propose that psy-
chedelic drugs can increase neural plasticity, which can allow greater modification of
previously established neural connections and therefore increase the ability to encode
changes being made in psychotherapy (e.g., Sarris et al., 2022). However, this area is
early in development and further research is needed to establish the efficacy, effect-
iveness, and mechanisms of action.

Conclusion
While depression is treatable, the mechanisms of change in psychotherapy remain
insufficiently tested to make strong conclusions about most specific components.
While all the models of therapy currently identified as evidence-based are derived
from testable theories, some have been much more strenuously tested than others.
Even for an approach like CBT, the level of component evaluation has been limited,
and specific hypothesis-driven predictions about the mechanism of change have
frequently failed to be supported (Zeiss et al., 1979; Jacobson et al., 1996).
Nonetheless, we believe that a theory-driven rather than an atheoretical
approach to treatment development and evaluation is critical to continued progress
in psychotherapy development. There are several approaches currently not
included as evidence-based with varying levels of scientific support for the
underlying theory. What does it matter if there is a weak theoretical frame if the
treatment is efficacious? We see three key concerns. First, while it is possible for
a poorly elaborated model to have some benefit based on the strength of nonspe-
cific factors, pursuit of hypotheses based on such outcomes to understand why
such an intervention was efficacious can lead to elaborations on a model that are
24 John R. McQuaid and Alfiee Breland-Noble

based on false assumptions and can draw effort and energy from interventions
more likely to be of benefit both in terms of outcome and in terms of informing
our understanding of mechanisms driving depression. Given the limited resources
available, we believe in focusing efforts on treatments with a sound theoretical
and evidentiary footing. Second, we believe that as providers we have
a responsibility to tell clients why the model being offered may lead to change.
Engaging with a model that is poorly understood or unsupported may lead patients
to erroneous assumptions about the nature of their disorder and change, and
contribute to difficulty in effective treatment engagement. Third, the reality is
that none of the treatments currently available are as effective as we would wish.
There is a critical need, as highlighted here, to determine the effective components
of treatments, refine them, and deliver them more effectively.
There are also key deficits in both access of patient populations to any evidence-
informed treatments and in what we know about the development and application of
various psychotherapeutic techniques to underrepresented groups. In reviewing what
is currently offered to patient populations, and particularly to intersectional people of
color (including LGBTQ, persons with disabilities, and geographically and/or socio-
economically diverse populations), little of the research upon which the guidelines
rely offers assessments of efficacy or effectiveness with these populations. As a result,
it remains unclear how these treatments work and whether they are equally effective
for the widest range of persons possible.
Future research is needed that addresses whether treatments need to be modified/
adapted for different groups and, if so, how. Focusing on addressing these research
gaps requires directing resources in a targeted manner, and this is most likely to be
successful when guided by scientifically sound theory and a desire to create general-
izable outcomes for public health.

Useful Resources

Treatment Guidelines
• American Psychological Association clinical guideline for treatment of depression: www.apa
.org/depression-guideline.
• VA/DoD clinical guideline for the treatment of depression: www.healthquality.va.gov/guide
lines/MH/mdd/.

Guidance Regarding Cultural Competence and Psychotherapy

• Sue, S., Zane, N., Hall, G. C. N., & Berger, L. K. (2009). The case for cultural competency in
psychotherapeutic interventions. Annual Review of Psychology, 60(1), 525–548.
 Depressive Disorders 25
• Breland-Noble, A. M. (2020). Community mental health engagement with racially diverse
populations. Academic Press.
• Breland-Noble, A. M., Al-Mateen, C. S., & Singh, N. N. (2016). Handbook of mental health
in African American youth. Springer.
• American Psychological Association guidance on culturally competent care: www.apa.org/
monitor/2015/03/cultural-competence#:~:text=Cultural%20competence%20%E2%80%
94%20loosely%20defined%20as,practice%20for%20some%2050%20years.

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 3
Bipolar Disorder
Monica Ramirez Basco

Bipolar disorder is a severe mental illness characterized by significant mood swings

that are accompanied by various cognitive (e.g., racing thoughts), behavioral (e.g.,
increased risk taking), and physical (e.g., decreased need for sleep) symptoms. It
affects approximately 1% of the population, about equally in men and women, and
generally has an age of onset in the early twenties (Merikangas et al., 2007).
People with bipolar disorder commonly suffer from episodes of mania and major
depression across the course of their lives once the illness begins. The pattern of these
episodes can vary greatly over time and across individuals. Between episodes, people
can be asymptomatic, experience some residual symptoms, or may have milder
episodes with limited functional impairment. If receiving pharmacotherapy, these
milder symptoms are sometimes referred to as symptom breakthrough because the
bipolar symptoms break through the protective effects of medication.
Depressive episodes that occur in the course of bipolar disorder are similar in
symptom presentation to those experienced as part of unipolar major depressive
disorder (MDD): significant and persistent sadness, loss of interest in usual activities,
sleep disruption, appetite and/or weight loss, slowed cognitive functioning, reduced
physical activity, and feelings of hopelessness (APA, 2022). When symptoms are
severe and persistent, hopelessness and an inability to overcome them can lead some
to consider suicide as an alternative. Across studies, Novick and colleagues (2010)
found that approximately 30% of study participants (range 24–46%) with bipolar
disorder reported at least one suicide attempt.
Episodes of mania can ramp up slowly before eventually reaching a peak that is
identifiable by its severity. For some, manic symptoms can occur together but be less
severe and not cause significant impairment. These are called hypomanic episodes.
Those who have had episodes of MDD and hypomania, but never mania, would be
diagnosed with bipolar II disorder (APA, 2022). That diagnosis changes to bipolar
I disorder if and when the individual experiences a manic episode.
The symptoms, time course, severity, comorbidities, and amount of functional
impairment experienced with bipolar disorder varies considerably across individuals.
30
 Bipolar Disorder 31

Similarly, the subjective experiences and outward presentations of manic and major
depressive episodes can vary within an individual over time. Some differences are due
to age of onset of the disorder, ongoing treatment, season of the year, psychosocial
stressors, comorbid problems such as substance abuse or dependence, or the presence
of psychotic symptoms. These variations not only present diagnostic challenges for
clinicians, but also make it difficult for people with bipolar disorder to understand
what they are experiencing, anticipate future episodes, and take preventive actions.
However, even with considerable variability in symptom presentation, people with
bipolar disorder can learn to become more attuned to the onset of hallmark symptoms
such as difficulty sleeping, poor concentration, or irritability, and take some actions to
control them. Such actions can include seeking or resuming medication treatment,
reducing stimulation in their environment, improving sleep habits, and discontinuing
use of substances that worsen depression or mania. These actions are often part of
relapse prevention plans created as part of cognitive-behavioral therapy (e.g., Lam
et al., 2003).

Etiology and Theoretical Underpinnings of Treatment

Science drives the psychotherapy treatment development process by informing the
conceptualization of a problem based on evidence of its existence and characteristics
and the choice of interventions that might ameliorate those documented symptoms. In
the case of bipolar disorder, for example, there is ample scientific evidence that
supports the characterization of bipolar disorder as consisting of manic and major
depressive episodes (Merikangas et al., 2007). Similarly, we already know a great
deal about the efficacy of cognitive therapy for the treatment of major depression
based on numerous clinical trials (Cuijpers et al., 2013). Therefore, it stands to reason
that depressive symptoms in the course of bipolar disorder could be similarly respon-
sive to the same types of interventions.
Science also helps us understand the biological, psychological, and social aspects
of mental illnesses. This knowledge helps the intervention developer identify possible
targets for treatment. For example, one of the common challenges observed in the
pharmacological treatment of bipolar disorder is the ability to consistently take
medication (Sylvia et al., 2014), often due to unpleasant side effects, limited under-
standing of the role of medication treatment in bipolar disorder, and the complexity of
treatment regimens (Loots et al., 2021). Targeting these challenges has become
a common strategy in cognitive-behavioral therapy for bipolar disorder (CBT-BP).
In the case of psychotherapy development, evidence-supported therapeutic models
for mental health disorders with similar symptom presentations can be adapted to
address new problems. For CBT-BP, a cognitive-behavioral model developed for
depression and other behavioral problems inspired the basic framework. For example,
physical symptoms in bipolar disorder, such as sleep or energy changes, can lead to
32 Monica Ramirez Basco

behavioral symptoms such as risk-taking, hypersexuality, or impulsivity in spending

money. CBT largely focuses on slowing down poor decision-making to give a person
time to use their reasoning skills before taking impulsive actions that might lead to
negative consequences. The advantages of working through CBT exercises with
a therapist is that the person in treatment learns about their illness, such as how to
recognize mood episodes as they begin to emerge. This puts them in a stronger
position to utilize interventions that can control the symptoms of bipolar disorder
early in their development.
The stage of the illness is important when choosing a CBT intervention for bipolar
disorder. For example, those newly diagnosed with bipolar disorder will need to gain
a thorough understanding of their illness through patient education, especially its
chronic and recurrent nature, as well as how treatment works. Those who take
medication for bipolar disorder but continue to have symptoms might seek therapy
to learn what they can do to make further improvements or how to better live with the
illness. Symptoms can interfere with learning, especially manic symptoms that
interfere with concentration, such as racing thoughts. CBT-BP methods may be easier
to learn when symptoms are mild.

Brief Overview of Treatments

Historically, the focus of treatment for bipolar disorder has been on use of mood
stabilizing medications solely or in combination with other drugs, which, when taken
consistently, can help stave off symptoms (Bowden, 2004). The development of
psychotherapy interventions for bipolar disorder began in the late 1970s as “add-
ons” or adjunctive treatments that helped people understand their symptoms and the
importance of consistent use of pharmacotherapy for the control of this chronic
mental health condition. The psychotherapy interventions with the best research
support will be discussed next.

Cognitive-Behavioral Therapy for Bipolar Disorder

Cognitive-behavioral therapy for bipolar disorder (CBT-BP, Basco & Rush, 1996,
2005) is a more comprehensive approach to psychotherapy for bipolar disorder and
has shown promise in reducing the risk of relapse (Lam et al., 2005), improving
adherence to medication treatment (Cochran, 1984), and enhancing day-to-day func-
tioning (Ball et al., 2006). CBT-BP was designed to help people cope better with
mood, cognitive, behavioral, and physical symptoms associated with this condition
and to reduce the risk of relapse. It was not intended as a substitute for medication
treatment, but instead is viewed as an adjunctive intervention to address the problems
that medication alone is often insufficient to fully address. While the purpose of
medication treatments is to resolve symptoms of depression and mania as well as to
 Bipolar Disorder 33

prevent future episodes, the goal of CBT-BP is to help people with bipolar disorder
play an active role in treatment by doing what they can to manage those aspects of
their illness over which they have control with the same end-points in mind. These
include gaining a better understanding of bipolar disorder and how treatment works so
that they are better prepared to take appropriate action as needed, learning how to be
consistent with taking medication, as well as knowing the early warning signs that
a new episode is emerging and working closely with their healthcare providers to
forestall it. In addition, CBT-BP helps people understand how their thoughts and
choices of actions may contribute to worsening of symptoms and what they can do
about it.
Like other cognitive and behavioral therapies described in this book, CBT-BP is
not a one-size-fits-all treatment. It is a group of interventions that are organized
around a theoretical model that explains problems and how to address them. For
example, the aspects of the treatment that are intended to help people recognize their
symptoms and which are more educational in nature might be helpful for people who
are new to the illness, had a recent onset, or are initiating treatment for the first time. It
helps them make sense of what is happening to them, to distinguish between normal
and symptomatic states, and to begin to draw a connection between treatment and
changes in these symptoms. For example, Perry et al. (1999) conducted one of the first
clinical trials with a psychoeducational focus using 7–12 individual therapy sessions
with people who had experienced a manic episode in the prior year. They found that
helping people understand their early symptoms of mania led to longer periods
without manic episodes as well as a reduction in the number of relapses into mania.
Similarly, Colom et al. (2003) found that in comparison to participation in support
groups, a 21-session CBT-BP group treatment with a psychoeducational focus for
people with bipolar disorder who were in remission helped to decrease hospitaliza-
tions and to increase time of wellness between episodes. The focus of the CBT-BP
intervention was on increasing awareness of symptoms, improving consistency in use
of medications, and promoting better understanding of the interplay between lifestyle
choices and symptom relapse.
Those who have experienced several episodes of depression or mania, and are
therefore more familiar with the symptoms of bipolar disorder, may benefit from
learning new methods to control symptoms when medication is not enough. Evans
et al. (2017), for example, focused on empowering people to take charge of their
treatment by learning to recognize the onset of mania and do what they could do to
help reduce their symptoms. Compared to treatment as usual (TAU), which consisted
of medication management, those who received the CBT-BP intervention had fewer
relapses and better psychosocial functioning over the 18 months following the
intervention.
A third group of individuals who can benefit from CBT-BP are those who
have had bipolar disorder for some time and have either had consistent difficulty
34 Monica Ramirez Basco

managing their illness (refractory bipolar disorder), or who seek therapy to help
them better adapt to or accept having the illness. Sometimes, people in this
group describe being tired of having to deal with symptoms and medication;
desire a break from pharmacotherapy; or need help managing their symptoms
when starting a new job, new relationship, or having a child. For example,
González-Isasi et al. (2010) found that participants receiving 20 sessions of
CBT-BP in a group format as part of treatment for refractory bipolar disorder
demonstrated better psychosocial functioning than did those receiving medica-
tion only. These examples illustrate the clinical flexibility of CBT-BP to address
the pressing concerns of people with bipolar disorder with broadly different
needs as well as to adapt the intervention to available treatment modalities and
services.
The development of the first published treatment protocol of CBT-BP (Basco &
Rush, 1996) was inspired by early efforts to provide psychotherapy to people with
bipolar disorder (e.g., Benson, 1975; Powell et al., 1977) and the work of Susan
Cochran (1984), who designed and tested a group-based intervention for improving
medication adherence in people being treated for bipolar disorder, a key strategy to
maximize the success of pharmacotherapy. Dr. John Rush, a protégé of the late
Dr. Aaron Beck who developed cognitive therapy for depression (Beck et al. 1979),
conducted some of the earliest clinical trials of cognitive therapy (Rush et al., 1977)
that supported the efficacy of this intervention. Dr. Rush saw the potential for utilizing
similar methods in the treatment of bipolar disorder as an adjunct to medication
treatment. Dr. Basco, a psychologist and researcher (and the author of this chapter),
had been developing cognitive-behavioral strategies for enhancing long-term treat-
ment adherence in Type I diabetes (Basco, 1993) as part of a multicenter clinical trial.
Together, Basco and Rush developed a protocol of cognitive-behavioral interventions
that could address the common challenges to stabilizing bipolar disorder, the first of
which was recognition and acknowledgment of the illness by the individual, their
support network, and their healthcare provider. Symptoms that generally required
treatment beyond pharmacotherapy included cognitive, behavioral, and affective
changes during episodes of bipolar disorder that were exacerbated by psychosocial
stress, inconsistent adherence to mood stabilizing medications, and actions that
contributed to the onset of new episodes.
Chiang et al. (2017) conducted a meta-analysis of 19 randomized-controlled trials
of CBT-BP with participants who had either bipolar I or bipolar II disorder. They
found that CBT-BP demonstrated an ability to lower relapse rates especially among
participants with bipolar I disorder, albeit with small to medium effect sizes. These
studies also demonstrated CBT-BP’s usefulness in helping participants to reduce
symptoms of depression and mania and improve their overall psychosocial
functioning.
 Bipolar Disorder 35

Care should be taken in comparing studies and formats of CBT-BP as the differences
in their delivery can make the intervention incomparable. For example, D’Souza et al.
(2010) examined the effectiveness of 12 sessions of group psychoeducation for patients
with bipolar disorder and their companions relative to TAU. The intervention was
shown to decrease the likelihood of, and the time to, relapse in the CBT group relative to
the TAU group. However, given that the CBT group differed in both the intervention
provided and in types of participants (patients only versus patients and their compan-
ions), it is difficult to know to which aspects that success can be attributed.
Keep in mind that therapy may be more effective than a placebo intervention for
many people, but it would be a mistake to assume it works for all people with bipolar
disorder even for interventions with sufficiently large effect sizes in support of its
efficacy. In fact, placebo interventions can sometimes be more effective than active
treatments for those who need what the placebo provides, such as a friendly ear, some
structure in their weekly schedule, or an activity that gets them out of the house.
Friendly human contact with someone with whom you can share thoughts and
feelings can be quite comforting. By the same token, the educational aspects of skills-
oriented therapies like CBT-BP, though shown to be effective for reducing symptoms
and preventing relapse, can feel rigid or unpleasantly academic for some patients. The
same is true for the format of treatment. Although shown to be effective, group CBT-
BP can be unpleasant for those who are socially uncomfortable, and individual
therapy can be unhelpful if a trusting therapeutic alliance cannot be established.

Family-Focused Therapy for Bipolar Disorder

Family-focused therapy (FFT) for bipolar disorder (Miklowitz, 2010) is a manualized
psychotherapy that capitalizes on the available support from family members, espe-
cially those who reside with the person who has bipolar disorder. Family therapy
sessions include education for all about the nature and management of bipolar
disorder, training to improve communication among family members, and strength-
ening of problem-solving skills to prevent or reduce stress. These skills, in turn, aim to
lessen the risk of relapse, reduce symptoms, and improve outcomes. As a component
of FFT, families create a relapse prevention plan that utilizes the skills developed
during FFT (Miklowitz & Chung, 2016).
In an exploration of the efficacy of manualized psychotherapies including FFT,
CBT, interpersonal therapy, and psychoeducation for bipolar disorder, Miklowitz
et al. (2021) summarized the outcomes of 20 RCTs. Study designs included random
assignment to either medication treatment in combination with either FFT, CBT,
interpersonal therapy, or psychoeducation, or to medication treatment with a control
condition such as supportive therapy or medication TAU. Results favored structured
and manualized treatments over unstructured supports, including lower rates of mood
episode recurrences.
36 Monica Ramirez Basco

Systemic Care for Bipolar Disorder

Unlike manualized psychotherapies such as CBT-BP or FFT, systemic care (Bauer,
2001), sometimes referred to as collaborative care, is a healthcare system-level model
of care that provides education, support, and symptom monitoring by clinicians for
people with bipolar disorder and assures that pharmacotherapy is consistent with
accepted treatment guidelines. Mental health care teams who are part of managed care
systems (Bauer et al., 2006a) are a central feature of systemic care and generally
include a treatment coordinator or case manager that serves as the patient’s point of
contact for care. This individual (often a nurse) connects patients to resources,
monitors symptoms and adherence to medication treatment, and facilitates crisis
intervention or other care services as needed.
RCTs of systemic therapy for bipolar disorder have focused on both patient
outcomes and costs of program implementation. Simon et al. (2006) recruited 441
patients from 4 behavioral health clinics that were part of a managed care organiza-
tion. Monthly telephone calls were used to monitor symptoms and treatment adher-
ence over the 2 years of the intervention, as well as to determine the needs for any
additional mental health services. When compared to TAU, those who had clinically
significant mood symptoms at baseline showed improvements in the severity and
duration of manic symptoms, but not depressive symptoms. The added cost of the
program over TAU was marginal. Similarly, Bauer et al. (2006b) randomly assigned
306 patients in 11 VA hospitals to systemic treatment or TAU and followed them for 3
years. They also found a reduction in duration of only manic symptoms with systemic
care as compared to TAU, with the added program of care being cost neutral.
In contrast, Van der Voort et al. (2015) conducted an RCT of systemic care as
compared to TAU for 138 patients with bipolar disorder in 16 outpatient mental health
clinics. Compared to TAU, systemic care led to greater improvements in severity of
depression at 12 months and duration of depressive symptoms at both 6 months and at
12 months. However, they did not observe differences in mania between the two
groups.

Credible Components of Treatments

There are several treatment protocols that fall under the rubric of CBT-BP. They share
similar theoretical foundations and treatment goals, but, depending on available
therapy time, will vary in how many interventions are taught or problems addressed.
There are also similar components across CBT-BP, FFT-BP, and systemic care such
as psychoeducation, skills for tracking and preventing relapse, and emphasis on
adherence to pharmacological treatment.
 Bipolar Disorder 37

Box 3.1 Research Therapists

The research supporting the efficacy of CBT-BP is based on well-established research

methods that aim to standardize as many aspects of the process as possible. That
includes use of valid and reliable methods for verifying a diagnosis of bipolar disorder
and measuring outcomes such as symptom level, appointment attendance, relapse,
and consistency with which medication is taken. While these methods are critical to the
ability to draw conclusions about the efficacy of CBT-BP, they can also make clinicians
unwittingly vulnerable to making therapeutic errors that can affect clinical outcomes.
The most common errors are those that send the wrong message to the person in
treatment that they are not as important as the research, such as failing to sustain
sufficient eye contact, seeming to lose track of what the person is saying while focusing
on protocol materials, or pushing an intervention that does not match well to the what
the person may need from the session.
For these reasons, the research therapists who provide CBT-BP in clinical trials are
trained on all methods and observed and rated for their abilities to provide the care as it
was intended while maintaining a strong therapeutic alliance. Not everyone is well-
suited to being a research therapist. It requires an ability to listen on several channels at
all times and to execute methods that, at times, might not feel like the right fit for the
moment. It is particularly challenging for therapists who in their private practices would
generally use a type of intervention that is different from the research protocol.
This being said, research therapists that contribute to clinical trials are usually
exceptional clinicians who willingly submit to being evaluated on their performance
and can tolerate corrective feedback. While it may not be necessary to perform CBT-BP
at expert levels, to achieve the results found in clinical studies therapists should receive
thorough training in psychopathology that includes bipolar disorder as well as good
basic training in cognitive-behavioral treatment methods.

Psychoeducation
A commonly used method across CBT-BP protocols is psychoeducation regarding
aspects of the illness and its treatment. Therapists can weave education around
discussion of the patient’s experiences with bipolar disorder, including symptoms,
patterns of occurrence and course of episodes occurring over time, and how
treatment works. Educational materials, pamphlets, workbooks, and worksheets
can be used between sessions to reinforce information covered or to help reinforce
concepts. Psychoeducation is easy to deliver within sessions, but therapists should
be cautioned to use it judiciously so that they are engaging in conversation rather
than talking at the patient for the full therapy hour. To facilitate rapport with
a new therapy patient, effective therapists do the following: (a) begin by asking
people what they already know about their bipolar disorder before providing
additional information, (b) inquire about what they have been told by healthcare
38 Monica Ramirez Basco

Box 3.2 Overcoming Challenges

There are several challenges to learning and administering CBT-BP, especially early in
one’s career as a therapist. Mastering technical skills may seem fairly straightforward,
especially when utilizing structured protocols, worksheets, and instructional manuals.
The hard part is doing these things while learning how to be a therapist, trying to
establish and maintain rapport with the person in treatment, learning about the myriad
of presentations of bipolar disorder, and dealing with comorbidities (e.g., substance
use, anxiety, significant life stress).
Another challenge is that mood swings and changes in thought processes and
content (i.e., racing thoughts, poor attention and concentration) can make it difficult for
the person with bipolar disorder to actively participate in therapy and to follow through
with the homework that is a hallmark of most CBT treatments. When distractibility and
a limited attention span make it difficult for the individual to focus during the session or
retain information gained in therapy sessions, the therapist can encourage the patient
to take notes and/or provide them with written materials. In some cases, it can be useful
and appropriate for the therapist to provide the written notes or to schedule a brief
phone call between sessions to follow-up on assigned homework, especially those
tasks that are critical to preventing an imminent relapse.
The therapist less experienced in working with people who have bipolar disorder
may also have trouble knowing when therapy progress is being stymied by the
symptoms of bipolar disorder versus problems with the therapeutic alliance or the
clinician’s limited skills. Clinical supervision for trainees and clinical consultation for
experienced therapists are useful tools when developing any new therapy skills,
including CBT-BP. It is also helpful to elicit feedback from the patient during sessions
about how the therapy is progressing, how they feel about homework assigned
between sessions, or any change they think would make the therapy process more
productive.
The fairly straightforward structure of most CBT-BP treatment protocols, especially
the educational ones, can cause some clinicians to eagerly jump into an intervention
before taking sufficient time to get to know the person they are treating and their unique
symptom presentation and experiences with bipolar disorder, or to get a feel for what
they already know about how to manage their illness. This mistake can diminish rapport
if it inadvertently communicates disrespect for their knowledge and skills. Every person
with bipolar disorder is different and has unique needs and abilities. In developing your
treatment plan, take time to listen to the person’s story before jumping too quickly into
an intervention. On the flip side, some people may have had many years of experience
with their bipolar disorder and its treatment, but still not be able to make the connection
between what they have subjectively experienced and the symptoms and treatment
effects. Helping people make that connection is a useful exercise that helps them
prepare for the next episode and to know when treatment is helping and when it’s not.
 Bipolar Disorder 39

providers or family members and ask if they agree, (c) demonstrate respect for
their experience with the illness by listening without correcting them, and
(d) make notes about future educational needs (Basco & Rush, 2005).
Psychoeducation is characterized by the Society of Clinical Psychology as having
“strong research support for mania and modest research support for depression”
(Society for Clinical Psychology, n.d., emphasis added).

Relapse Prevention
Patient education and improving adherence to medication treatment are two important
aspects of preventing relapse, another goal common in CBT-BP protocols. Preventing
episodes of depression and mania begins with education around common symptoms.
The next step is to teach strategies for monitoring and detecting those symptoms,
especially those that a person typically experiences early in the course of an episode.
Examples of such methods include tracking mood swings, making note of changes in
sleep patterns, or selecting a feeling or action that has previously preceded the onset of
depression or mania (Basco, 2015).
Early detection of relapse provides an opportunity for early intervention. These
might be self-help interventions taught during CBT-BP, strategies used by the ther-
apist, or engaging a healthcare provider that manages medication treatment.
Therapists should become knowledgeable of common things that trigger manic
episodes, such as sleep loss or overstimulation, or that worsen feelings of depression,
such as rumination or social isolation. Discussion of such triggers can become part of
an action plan to avert a relapse.

Cognitive Restructuring
Traditional cognitive restructuring methods like those introduced by Beck et al.
(1979) are also commonly used tools in CBT-BP. They can be used to educate people
about common changes (distortions) in thinking that can occur during periods of
depression and mania and how to reason through them. For example, discussions
around the logical errors that discourage consistent use of pharmacotherapy can help
people gain a better understanding of how medications work and can help them learn
to distinguish between valid concerns and those driven by the symptoms of bipolar
disorder. An example might be mistaking the onset of a manic episode for their new
normal and seeing no need to continue taking medication. Cochran (1984), for
example, taught cognitive restructuring skills to help medication group participants
fight the urge to stop treatment. More consistent use of pharmacotherapy helped to
increase the time to relapse and reduce the number of relapses as compared to
a standard care comparison group focused on medication management.
40 Monica Ramirez Basco

Social Support
One of key advantages of FFT and systemic interventions is their engagement of other
people to assist in treatment (Bauer, 2001; Miklowitz, 2010). FFT’s engagement of
family members and systemic care’s use of care managers that communicate with
treatment team members help with the monitoring, recognition, and response to
emerging symptoms of depression and mania in the person with bipolar disorder.
FFT has the added advantage of working directly with family members, strengthening
their coping skills along with patients’ skills.

Approaches for Youth

Research on the usefulness of psychotherapy for preventing or reducing the symptoms
of bipolar disorder in youth is limited to date. In general, studies of psychotherapeutic
interventions, such as FFT, Interpersonal/Social Rhythm Therapy, and CBT, have
shown some evidence of their abilities to reduce symptoms and lengthen the time
between mood episodes when compared to TAU such as medication clinic or sup-
portive care (Miklowitz et al., 2021). Unfortunately, there have been no sufficiently
powered studies to date that specifically compare CBT to other standardized psycho-
therapeutic interventions in youth with bipolar disorder.
Some information, however, might be gleaned from examining the treatment
responses of people in psychotherapy clinical trials who are earlier in their course of
illness of bipolar disorder, and therefore presumably younger. Ratheesh et al. (2023)
found that when compared to those receiving TAU, study participants early in their
course of bipolar disorder had improved symptoms and a reduced risk of relapse in
studies of FFT (which included teens), and with CBT – with the youngest participants
being primarily young adults. Similarly, Colom et al. (2010) found that psychoeduca-
tion focused on bipolar disorder was superior to supportive psychotherapy for partici-
pants with less than six episodes of illness compared to those with a longer course of
bipolar disorder. Number of episodes can be a proxy for age in some cases.
CBT for major depressive episodes has not yet been tested in clinicals trials of
youth with bipolar disorder. However, there have been studies of CBT for unipolar
depression in adolescents, albeit with mixed findings (Kennard et al., 2006). See
Chapter 2 for more information about unipolar depression with youth.

Other Variables Influencing Treatment

Assessment and Diagnosis
What distinguishes bipolar disorder from MDD is the occurrence of manic episodes.
The mood changes in mania can be experienced as euphoric, excited, happy, up, or
excessively irritable. These emotional shifts are intense and much more pronounced
 Bipolar Disorder 41

than reactions one might have to good or bad events. However, the experience of
mood is very subjective. For people who are generally in good spirits, it’s not
unusual to be in an up mood that is not a symptom of mania. Likewise, in people
that tend to be easily annoyed or are difficult to please, an irritable mood might not
stand out as extreme. To be accurate in evaluating the presence of mania, clinicians
must consider the full array of symptoms associated with bipolar disorder – those
described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition, Text Revision (APA, 2022). These symptoms include a decreased need
for sleep, uncharacteristic talkativeness, distractibility, racing thoughts, or restless-
ness. Because self-awareness can be limited when manic symptoms are present, it is
useful to gather information from family members, friends, or other healthcare
providers who have had more opportunities to observe the person when symptoms
are present.
A definitive diagnosis of bipolar disorder is difficult to make during childhood
and adolescence for many reasons. The behavior changes that occur during
episodes of depression or mania can be misinterpreted as the primary problem
rather than part of a symptom constellation consistent with depression or mania.
Attention problems common to both phases of the illness might be viewed as
attention-deficit/hyperactivity disorder (ADHD) if the additional mood symptoms
are not carefully evaluated. Perhaps most challenging is to differentiate MDD
from bipolar disorder in youth when depressive episodes present before the first
manic episode. Occurrence of a manic episode is required before a diagnosis of
bipolar disorder can be accurately determined. Given that CBT-BP is heavily
weighted on patient education about the illness and its treatment, care should be
taken to carefully assess the symptoms of bipolar disorder for initiating the
intervention.

Comorbidity
Common comorbidities in youth with bipolar disorder include anxiety disorders,
oppositional defiant disorder, and substance abuse (Post & Grunze, 2021), some of
which may have predated the onset of the mood disorder. Duffy et al. (2019) studied
Canadian youth who were offspring of adults with bipolar disorder, thereby making
them at high risk for having the illness. They found that bipolar disorder was predated
by a sequence of other mental health problems. Anxiety, ADHD, and sleep problems
occurred before the onset of minor mood episodes and adjustment disorders. This
sequence is supported by Merikangas et al.’s (2010) findings in the National
Comorbidity Survey-Adolescent Supplement which showed a median age of onset
for anxiety for adolescents of 6 years and a later median age of onset of 13 years for
mood disorders such as bipolar disorder. Substance use disorders tended to occur
later, with a median age of onset of 15 years.
42 Monica Ramirez Basco

The evolution of mental health problems in youth over time is a challenge for
clinicians. They are in the position of treating current symptoms without the benefit of
knowing what will happen next. For psychotherapists, any intervention that provides
knowledge and coping skills can be helpful. If new symptoms emerge, psychothera-
peutic methods such as CBT-BP can be added to address new problems. Healthcare
providers that prescribe medication treatments for depression have the more daunting
task of selecting drugs that could create new problems, such as triggering the onset of
mania.

Demographics
The evaluation of the efficacy and effectiveness of CBT-BP is still in the early stages.
Meta-analyses of studies to date (e.g., Miklowitz et al., 2021) show its promise, but
more work must be done before conclusions can be drawn about for whom it is
a preferred treatment option. Like with any other psychotherapy, clinicians should
gather information about a person’s demographic, cultural, social, and family back-
ground to help inform their conceptualization of the presenting problem and the
selection of treatment options.

Medication
A commonly used component of CBT-BP is establishing, improving, or maintaining
adherence to medication regimens. This begins during the education phase of therapy
by talking with the individual about current or past treatment, times when adherence
has been challenging, and occasions when it has not been a problem. Studies that have
compared medication clinic visits only to those with additional CBT-BP sessions have
demonstrated the advantage of therapy as a complement to providing medication
alone (Cochran, 1984; Evans et al., 2017; Perry et al., 1999). CBT-BP allows people
to talk about their problems, address concerns about medications such as side effects,
and correct negative and inaccurate thoughts about having a mental illness that
requires pharmacotherapy. Once a person is ready to commit to medication treatment,
therapists can help by establishing open communication about treatment adherence
with the patient and the prescribing clinician, as well as assisting in the design of
a personalized plan for taking medication consistently.

Conclusion
CBT-BP, FFT, and systemic care have been shown to be effective and useful
psychotherapeutic tools for bipolar disorder, especially when part of a treatment
package that includes pharmacotherapy. While there can be challenges to implemen-
tation, the efficacy of empirically supported treatments is well worth the effort in
 Bipolar Disorder 43

helping to improve the quality of life of people with bipolar disorder. Because of the
lifelong nature of the illness, the usefulness of therapy has the potential to be more
helpful than can be measured in a clinical trial with limited treatment and follow-up
periods. Each episode of depression, mania, and hypomania provides people with
bipolar disorder, as well as their healthcare providers and family members, with
opportunities to learn more about the illness, its triggers, and ways to prevent recur-
rences, thus improving quality of life.
For trainees who wish to gain skills in empirically supported treatments for bipolar
disorder, there is much to be learned from formal training opportunities in the
classroom and in clinical settings, especially those that provide supervision from
clinicians with extensive experience in the treatment of bipolar disorder. In truth,
savvy clinicians continue to learn from their successes and challenges in the course of
providing care for people with bipolar disorder, particularly given the variety in
symptom presentations of the illness and the many other things people bring with
them to the therapy experience. Trainees are encouraged to view these experiences as
not just clinical encounters, but as gifts of knowledge provided by people who will
teach a great deal about how to be helpful and keep humble about therapeutic skills.

Useful Resources

• National Institute of Mental Health (NIMH), Bipolar Disorder, www.nimh.nih.gov/health/

topics/bipolar-disorder.
• National Alliance on Mental Illness (NAMI), https://nami.org/About-Mental-Illness/
Mental-Health-Conditions/Bipolar-Disorder.
• Depression and Bipolar Support Alliance (DBSA), www.dbsalliance.org/education/bipolar-
disorder/.
• Substance Abuse, and Mental Health Services Administration (SAMHSA), www
.samhsa.gov/serious-mental-illness/bi-polar.
• American Psychiatric Association. Bipolar Disorders, www.psychiatry.org/patients-fam
ilies/bipolar-disorders.
• American Psychological Association. Bipolar Disorder, www.apa.org/topics/bipolar-
disorder.
• US Department of Veteran Affairs. Bipolar Disorder. www.mentalhealth.va.gov/bipolar/
index.asp.
• Basco, M. R. (2015). The Bipolar Workbook: Tools for Controlling your Mood Swings, 2nd
ed. Guilford Press.

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 4
Anxiety Disorders
Dean McKay

Anxiety disorders are the most common category of psychiatric conditions, with base
rates in the population actually increasing in the past several years. Recent population-
based surveys suggest that as many as 33.7% of the population has been significantly
affected by anxiety in their lifetime (Bandelow & Michaelis, 2022). As a category of
diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR;
American Psychiatric Association, 2022), anxiety disorders are comprised of gener-
alized anxiety disorder, panic disorder, specific phobia, social anxiety disorder,
agoraphobia, separation anxiety disorder, and selective mutism.
Across the range of anxiety disorders, there are empirically supported treatment
protocols and guidelines for developing evidence-based approaches in everyday
clinical practice. As the scope of these protocols is extensive, this chapter focuses
primarily on alleviating anxiety in general, and offers resources for readers to identify
methods of interventions for specific anxiety disorders.
Anxiety disorders are marked by several core features. First, sufferers experience
heightened sympathetic nervous system arousal, resulting in increased heart rate,
muscle tension, respiration, and associated physiological arousal. This arousal is in
response to specific feared stimuli or situations. Second, sufferers typically experi-
ence anticipatory anxiety, as they expect to encounter feared stimuli and situations.
Third, anxiety disorder sufferers engage in avoidance of associated stimuli and
situations, a process that may foster a wide range of cognitive distortions that
perpetuate avoidance behavior. Collectively, these three domains contribute signifi-
cantly to disability associated with anxiety disorders.

Etiology and Theoretical Underpinnings of Treatment

Contemporary models of anxiety disorder etiology emphasize its emergence from
a personality predisposition connected with specific biological risks. Neuroticism,
a broad personality trait that has been linked with sensitivity to aversive experiences
and lower reward sensitivity, is associated with the full range of anxiety disorders, as
47
48 Dean McKay

well as depression (Barlow et al., 2014). This sensitivity to aversive experiences sets
the occasion for a higher rate of acquired feared stimuli and situations. This higher
rate of acquisition can come about through direct experience, or through informa-
tion processing and cognitive biases toward feared stimuli (discussed in McKay,
2016).
Each of the distinct anxiety disorders listed in the DSM-5-TR have well-established
cognitive-behavioral treatment protocols. The varied protocols all emphasize target-
ing behavioral avoidance and cognitive distortions associated with anxiety onset and
maintenance. These strategies, collectively, can be viewed as targeting neuroticism
(Barlow et al., 2014). In recognition of this common thread among the anxiety
disorders, the Unified Protocol (UP; Farchione et al., 2012) was developed to alleviate
anxiety disorders and depression. The remainder of this chapter emphasizes interven-
tion with the UP, while also recognizing the contribution to understanding the
mechanisms of specific anxiety disorders resulting from research on other specific
treatment protocols.

Brief Overview of Treatments

As noted, the emphasis in this chapter is on the UP as a treatment for anxiety
disorders. However, across all treatment protocols, there is an emphasis on several
interventions to varying degrees: exposure, cognitive therapy, and general emotion-
focused coping strategies. The UP specifically enumerates five broad intervention
domains: increasing present-focused emotion awareness, increasing cognitive flexi-
bility, identifying and preventing patterns of emotion avoidance/maladaptive emo-
tion-based behaviors, increased tolerance of emotion-based physical reactions, and
interoceptive and situational exposure. Each of these treatment components of the
UP can be classified into exposure (interoceptive and situational exposure;
increased tolerance of emotional-based physical reactions), cognitive therapy
(increased cognitive flexibility), and general emotion-focused coping strategies
(increasing present-focused emotion awareness, identifying and preventing patterns
of emotion avoidance/maladaptive emotion-based behaviors). What has been valu-
able about the development of the UP has been the portability and ease of dissemin-
ating to a wide range of settings where clinicians might otherwise be overwhelmed
by the choice of treatment packages for the various anxiety disorders (McHugh &
Barlow, 2010).

Exposure-Based Interventions
A core behavioral intervention for all anxiety disorders, exposure is seductively
simple in its description, but technically challenging to implement. The central feature
of exposure therapy involves gradually and systematically presenting feared stimuli
 Anxiety Disorders 49

or situations to clients, so that these previously avoided stimuli and situations are
better emotionally tolerated. When possible, in vivo exposure should be conducted.
Research has demonstrated that live exposure is most effective in alleviating anxiety
and reducing exposure. When practiced in vivo, the clinician’s role is to facilitate the
exposure experience with imagery that highlights the feared outcome from the
exposure (discussed in Garner et al., 2021). This is in order to reduce any potential
cognitive avoidance the client may engage in that would undermine the effectiveness
of the live exposure.

Cognitive Therapy
Modern cognitive therapy is based on two broad components. The first is that
individuals have biases of thinking that foster beliefs that have not been critically
examined. Therefore, one component of cognitive therapy is to train clients to
approach their beliefs scientifically, and test out the assumptions they hold regard-
ing different situations. In the anxiety disorders, there are some broad themes into
which these beliefs roughly fall, such as intolerance of uncertainty and overesti-
mation of threat (see Clark & Beck, 2009). The second component is based on
findings from cognitive science, in which individuals with anxiety disorders
differentially attend to, and therefore differentially encode into memory and
form judgments in response to, greater amounts of threat-related information
from the environment (discussed in Williams et al., 1997). This line of experi-
mental cognitive research has led to recent computer-based interventions aimed at
retraining individuals to attend to nonthreatening stimuli (Hang et al., 2021).
Regardless of the application of computer-based attention retraining methods,
understanding cognitive biases is useful in informing clinicians about how anxious
individuals may show differential attention and memory, and guide how to facili-
tate gathering of evidence for clients to use in challenging their assumptions about
feared situations.

Emotion-Focused Coping Strategies

The range of interventions that fall in this category is diverse. It includes direct
physical interventions such as relaxation training (Manzoni et al., 2010) up to
more recent developments such as mindfulness meditation (Hofmann et al.,
2010). These approaches are often integrated into existing treatment packages
for anxiety disorders. Recent research suggests that mindfulness, and some
related interventions (such as acceptance-based treatments; see Box 4.1), pro-
duce large effects on anxiety reduction (Vøllestad et al., 2012). Although these
approaches have generated considerable enthusiasm among anxiety disorder
specialists, their unique contribution to symptom reduction remains unclear.
50 Dean McKay

Overall Level of Research Support

The aforementioned broad treatment approaches for anxiety disorders enjoy substantial
research support when examined as full treatment packages. However, support for
treatment packages does not provide information regarding which components are
essential, whether the sequence of interventions is optimum, or whether any components
may be benign or even detrimental to outcome. Discussion of dismantling research and
investigations of individual components are presented in the following sections.
The standards for empirically supported treatments (ESTs) recently underwent
revision (Tolin et al., 2015). In the revised EST standards, a well-established treatment
had to have a sufficient body of research support, in high-quality investigations, that the
protocol would fare well in systematic reviews and meta-analyses. When considered in
this light, few research protocols for anxiety disorders yet reach that standard, including
the UP that has served as the central protocol for this chapter. However, the accumu-
lated research over the past four decades into exposure therapy and cognitive therapy
suggests that together these serve clients with anxiety disorders well, and may be
reasonably considered the basis for treatment. In particular, using the original EST
criteria, the Society for Clinical Psychology (n.d.) indicates there is strong research
support for: (a) exposure therapies for specific phobias, (b) cognitive and behavioral
therapies for generalized anxiety disorder, (c) cognitive-behavioral therapy for panic
disorder, and (d) cognitive-behavioral therapy for social anxiety disorder.
The addition of emotion-focused coping strategies, however, is less clear. As
a stand-alone set of interventions, these would not be considered sufficient to alleviate
anxiety. Indeed, research has demonstrated that relaxation training alone leads to
moderate effect sizes (Manzoni et al., 2010), as does mindfulness meditation
(Hofmann et al., 2010). Contrast that with the effect sizes for exposure, which are
typically large (discussed in Garner et al., 2021).
The UP has accumulated sufficient research that a systematic review has been
conducted, showing large effect sizes for the treatment protocol (Sakiris & Berle,
2019). However, this review included adaptations of the UP to other diagnostic
groups (such as eating disorders), treatment-seeking adults with a range of emotional
distress, and studies that were single-subject or nonrandomized in nature. So, while
there is cause for optimism that the UP may reach a level of being considered an EST
(based on the recent criteria, Tolin et al., 2015), there are not yet sufficient high-
quality investigations for a systematic review to evaluate.

Credible Components of Treatments

The discussion to this point has emphasized multicomponent intervention programs to
alleviate anxiety disorders. However, to be fair, there have been few dismantling
studies to isolate the individual interventions that form the basis for the existing
 Anxiety Disorders 51

Box 4.1 Acceptance and Commitment Therapy

Among psychosocial treatment packages, the vast majority emphasize cognitive-

behavioral approaches. Some recent treatment programs have also included a role for
acceptance and commitment therapy (ACT; Hayes et al., 2016). Briefly, ACT is based on
a modern verbal-learning theoretical framework called relational frame theory
(discussed in Hayes & Hayes, 1992; Zettle et al., 2015). In a review of meta-analyses
(Gloster et al., 2020), eleven studies reported effect sizes for anxiety reduction applying
this treatment approach, and these effect sizes were small to moderate. Although ACT
may contribute significantly to anxiety reduction, at the present time it may be best
viewed as a contribution to other comprehensive treatment programs rather than as
a stand-alone intervention.

treatment protocols. The few investigations that have been conducted have compared
exposure to cognitive therapy, with no significant difference between interventions
(discussed in Kaczkurkin & Foa, 2015). It should be noted, however, that exposure
and cognitive therapy each contain components of the other, thus complicating any
“pure” comparison between the two.

Aspects of Exposure
The underlying science of exposure has evolved significantly in the past ten
years. Foa and Kozak (1986) articulated the dominant conceptualization for the
mechanisms underlying exposure, a perspective that has guided the treatment
literature for decades. Specifically, the requirements for exposure to exert its
effect on anxiety demanded that the intervention provoke adequate arousal to
engage the neural circuitry associated with fear and its connection to memory
structures that stored the fear information. However, this came with a risk that
the therapist might evoke too much fear, leading to a breakdown in the ability to
benefit from the intervention, and instead would further crystallize the memory
for the fear. This model, where the minimum requirement in each session was
the evocation of fear, led to some unfounded apprehensions among clinicians,
including concerns that there would be higher rates of client drop-out and risk of
litigation (Richard & Gloster, 2006).
More recently, exposure methods have shifted to the inhibitory learning model
(ILM; Craske et al., 2014). In this approach to exposure, the emphasis is on new
learning, irrespective of clients’ emotional reaction during the session. This model
details several major ways that exposure procedures may be adjusted to target facets
of classically conditioned fear and/or the associated avoidance. The author of this
chapter has described the ILM as an approach intuitively applied by clinicians who are
successful in implementing exposure, given that there is a de-emphasis on provoking
52 Dean McKay

anxiety and an emphasis on new behavior (Frank & McKay, 2019). However, the
empirical support for the ILM has not been systematically tested, and thus as of this
writing may be best considered a potential format for administering exposure that
deserves greater empirical scrutiny. Interested readers are directed to Craske et al.
(2014), as well as Jacoby and Abramowitz (2016) for detailed descriptions of the
approach.

Intersection of Exposure and Cognitions

The prescription of exposure to alleviate fear is not done in a vacuum. Indeed, if
mere exposure were easily accomplished by direct instruction, there would be little
use for the clinician. Instead, clients need to have the procedure explained to them,
with suitable justification for the effects on their anxiety that it will produce. The
process of demonstrating that exposure will, ultimately, have some benefit typically
includes a direct confrontation with the feared consequences and some challenge to
the veracity of these consequences: In short, cognitive therapy but without the actual
disputation and direct targeting of cognitions (discussed in Kaczkurkin & Foa,
2015).
Exposure in general may also serve to facilitate cognitive therapy. The following
are two major ways this can be accomplished.

Increase Relevance of Cognitions

As imagery is constructed in conjunction with exposure, the associated cogni-
tions become more accessible. This increased accessibility makes exposure an
important accompaniment to cognitive therapy in order that robust challenges to
the automatic biases may be undertaken. Therapeutic situations that raise the
relevance of cognitions increase their accessibility, and thus are more readily
targeted as part of cognitive therapy (discussed in Abramowitz, Taylor, &
McKay, 2006).

Hypothesis Test Additional Cognitions

Cognitive science models emphasize that automatic processing entails attentional
biases, which in turn influence memory and judgment. Accordingly, imagery exer-
cises that accompany exposure may also serve the purpose of testing hypotheses the
clinician may have regarding the putative anxiety-related stimuli that the client may
not readily identify (discussed in Mathews, 1997). Imagery exercises serve an import-
ant purpose by targeting biases in attention and memory that accumulate from
a process of chronic avoidance. That is, the persistent avoidance allows anxiety
disorder sufferers to maintain untested beliefs, and hypothesis testing allows for the
systematic breakdown of these biases.
 Anxiety Disorders 53

Addressing Cognitive Biases

Modern cognitive therapy for anxiety disorders builds on prior iterations of the
approach by highlighting empirically validated cognitive biases commonly observed
among individuals with this class of disorders. The original formulation of cognitions
for anxiety disorders was most clearly described by Beck and Emery (1985), where
future-oriented catastrophic cognitions were spontaneously accessible to anxiety
sufferers. This general model has since been refined to emphasize the following
cognitive biases. Each of the belief domains listed here warrant a range of cognitive
therapy interventions, such as behavioral experiments (to directly test hypotheses),
practice in disputation, and rehearsal in coping with circumstances where hypothetic-
ally the feared outcome might come true.

Intolerance of Uncertainty
This specific cognitive bias is highly prevalent in the anxiety disorders, with meta-
analyses showing it correlates significantly with symptoms of generalized anxiety
(Gentes & Ruscio, 2011). It has also been shown to be highly correlated with general
symptoms of emotion dysregulation (Sahib et al., 2023).

Perfectionism
The tendency toward perfectionism has long been associated with anxiety (e.g.,
Antony et al., 1998), as well as representing a specific risk for depression and
suicide (Blatt, 1995). Additional systematic data show that perfectionism is
highly predictive of the full range of anxiety disorders (Egan et al., 2011), and
that direct treatment of perfectionism has palliative effects on anxiety in general
(Galloway et al., 2021).

Overestimation of Threat
When individuals with anxiety disorders describe the objects and situations that
provoke fear, it is often through the perspective of the dangerousness of the stimuli.
A reasonable question that clinicians ask, then, is what is the level of risk? This
question demands the client provide an appraisal of the hazard associated with the
stimuli. Thus, to use a basic example, when individuals suffer from spider phobia, the
appraised dangerousness of spiders is high, even though the actual number of spiders
that are deadly to humans is extremely low. This kind of danger appraisal breakdown
could be done with any presenting anxiety concern. Further, findings from experi-
mental cognition research show that as anxiety increases, attentional bias is increased
for more subtle threats, which in turn biases memory for danger (Pergamin-Hight
et al., 2015).
54 Dean McKay

Approaches for Youth

As with adult anxiety disorders, there are numerous ESTs for childhood anxiety. These
protocols generally emphasize exposure and cognitive therapy, scaled to address the
unique developmental needs of youth. As with the UP for adults, there is a protocol that
has gained wide adoption for the treatment of anxiety disorders in youth: the Coping Cat
(Kendall, 1994). Key components of the Coping Cat program include exposure, cogni-
tive reappraisal methods, and relaxation strategies. Reappraisal strategies in children
involve presenting situations where the child has to describe hypothetical thoughts that
might accompany it and then generate other reasonable options. For example, in Coping
Cat, there is a cartoon image of a large, ostensibly aggressive dog on a leash, and a cat
that is clearly out of reach of the dog. The child would be asked to generate potential
thoughts the cat may have in this situation.
The Coping Cat treatment program has been modified for adolescents (Podell et al.,
2010) and frameworks have been developed to flexibly adopt the program based on
complex clinical presentations and comorbid conditions (Beidas et al., 2010). Meta-
analytic findings suggest that, compared to waitlist or control treatment conditions,
the effect of the Coping Cat program on reducing anxiety and associated psychopath-
ology is large, and when compared to other credible treatments the effect is small
(Lenz, 2015).
Treatment of child anxiety often engages the parents in the process. The majority of
treatment programs, including the Coping Cat, specify a role for parents related to
aiding the child in practicing the core components of the protocol. However, research
has consistently shown that parental involvement based solely on assisting in expos-
ure and cognitive interventions has a negligible effect on treatment (Reynolds et al.,
2012). The current conceptual models of treatment emphasize anxiety reduction
without examining the environmental context in which it develops or is maintained,
despite the foundation of behavioral interventions being based on learning experi-
ences. Thus, there have been calls for programmatic developments of interventions
that integrate parent and family variables that might foster anxiety in children and
target those in addition to the already established and effective components of existing
protocols (Taboas et al., 2015).

Other Variables Influencing Treatment

Assessment and Diagnosis
The chapter thus far has described treatment approaches for the majority of cases,
without necessarily considering potential complicating factors. Identifying these
potential complicating factors can be critical in developing a case conceptualization
that would increase the likelihood of a good outcome. Research has shown that
variables such as comorbid psychopathology, personality disturbance, and
 Anxiety Disorders 55

medication may impact adherence to treatment and drop-out (Taylor et al., 2012).
Several major areas of potential treatment complications are reviewed.

Comorbidity
Depression commonly co-occurs with anxiety disorders. The connection between
anxiety and depression has been recognized for a long time (i.e., Dobson, 1985; Rapee
& Barlow, 1991). While it is acknowledged that anxiety and depression are separate
conditions, depression associated with anxiety disorders is generally understood to
result from the loss of control over the emotional arousal and range of situations that
are associated with feared stimuli and situations (Beuke et al., 2003).
Comorbid conditions are generally considered additional barriers to treatment
outcome. Interestingly, the consequence of different comorbid conditions on treat-
ment outcome has not been widely or systematically evaluated, despite the finding
that the vast majority of participants in treatment trials have one or more additional
diagnoses (Newman et al., 2010). In one meta-analysis that considered all treatments,
and not solely evidence-based interventions, it was shown that any additional comor-
bid condition was associated with poorer outcome (Olatunji et al., 2010).
The one class of disorders that stands out for a potential adverse effect on anxiety
disorder treatment outcome are substance use disorders. Interestingly, there is com-
parably limited research on this (McHugh, 2015). This gap in the research is surpris-
ing considering that survey data has shown that anxiety disorders are a risk factor for
substance use (Marmorstein, 2012).

Demographics
Research into demographic factors that might impact anxiety disorders has been
conducted, and generally does not reveal any substantive effects, with one exception.
It has been noted that anxiety disorders tend to affect women more than men (Craske,
2003), with risk for anxiety disorders at about twice the rate as for men. There is limited
research on the full range of gender identities as yet, and the majority of the body of
research is on traditional binary gender definitions. It has been suggested that this
increased liability for anxiety in women is multifaceted but centers on biological
differences in hormonal regulation and, consequentially, brain area action. The explan-
ation for these differences remain largely theoretical. Research has shown that there are
no differences in treatment outcome based on gender (Grubbs et al., 2015).

Medication
There are a diverse range of practice guidelines for anxiety disorders that have
originated from several professional organizations. Thus, these guidelines emphasize
the treatments that are generally within the purview of that organization. For example,
56 Dean McKay

while the evidence for medication in the treatment of anxiety disorders is generally
positive, it is less clear the extent to which psychopharmacology is additive to
psychosocial interventions (Olatunji et al., 2010). Despite this, most psychiatric
organizations make the blanket recommendation for a combination of CBT with
psychopharmacology (i.e., Bandelow et al., 2012).
There is a large body of research that examines the conjoint role of medication
(usually antidepressants) and CBT in the anxiety disorders. As noted, while the
majority of psychiatric clinical practice guidelines suggest that the best outcome is
a combination of both, the research actually suggests some medications (such as
benzodiazepines) may interfere with long-term benefits of CBT (Otto et al., 2005;
Tolin, 2017).
Benzodiazepines (or minor tranquilizers) are commonly prescribed for anxiety
disorders. This class of medications alleviate acute anxiety, and many anxiety dis-
order sufferers may be prescribed one of these drugs to take daily, rather than as
needed. The difficulty this poses is that benzodiazepines also lead to physical depend-
ence, and withdrawal symptoms upon discontinuation (see Julien et al., 2010 for
a detailed discussion). Frequently, when individuals with anxiety disorders initiate
CBT, particularly exposure therapy, the clinician may suggest that the client refrain
from taking benzodiazepine medications as the sedating effects interfere with the
elicitation of arousal necessary for exposure to have its benefits. As a result, individ-
uals who have developed benzodiazepine dependence may require additional treat-
ment specifically directed at managing withdrawal. Cognitive-behavioral therapy
procedures specifically aimed at facilitating benzodiazepine discontinuation have
been developed, and are found to be efficacious (Takeshima et al., 2021).

Box 4.2 Personality and Anxiety Disorders

Anxiety disorders are most closely associated with the personality trait of neuroticism,
and there has been a recent resurgence in interest in this attribute (Barlow et al., 2014).
This is the specific target personality trait at the heart of the UP, and, given the broad
recognition of its role in a wide range of internalizing disorders, it is reasonable that it
would be the focus of attention in evidence-based treatment.
Other personality variables have also been examined in relation to treatment
outcome for anxiety disorders. For convenience, relying on the personality factors that
form the “Big 5” (Costa & McCrae, 2008), the additional four traits would be
extraversion, conscientiousness, agreeableness, and openness to experience. Recent
research has shown that extraversion is a protective factor against the development of
anxiety disorders (Metts et al., 2021). Research on conscientiousness and openness to
experience are fairly lacking, but one investigation showed no meaningful association
between these two traits in predicting anxiety disorder onset or severity (Karsten et al.,
2012). In one meta-analysis that examined the relation of all the personality factors in
 Anxiety Disorders 57

the Big Five to anxiety, depressive, and substance use disorders, it was shown that
extraversion had the highest protective value, and conscientiousness also provided
some protection, whereas conscientiousness and openness to experience were
generally unrelated (Kotov et al., 2010).
Although personality assessment is a common procedure in clinical settings, and
conceptual research frequently emphasizes the negative prognostic indicators for co-
occurring personality disorders for virtually all psychopathology, there remains limited
research on how personality traits or disorders impact treatment outcome for anxiety
disorders. One recent review examined all the available research, dating from 1980 to
2019, and identified only 48 studies that evaluated personality traits or disorders in
predicting anxiety disorder treatment outcome (Hovenkamp et al., 2021). They found
that personality disorders did, in fact, tend to predict poorer treatment outcome. For
personality traits, they found that low levels of extraversion were associated with poorer
outcome, and higher levels of attributes often broadly associated with neuroticism were
also associated with poor treatment outcome.

Conclusion
Anxiety disorders have been heavily investigated, and ESTs have been devel-
oped that emphasize cognitive-behavioral models of intervention. A recent
protocol, the UP, served as a useful framework for discussing the critical
components of evidence-based treatment as it emphasizes exposure, cognitive
modification, and specific coping strategies. While the available research on
these conditions shows that effective treatments are available, and that these
alleviate symptoms as well as improve quality of life, there remain significant
gaps in research knowledge.
Addressing stigma, a known impediment to treatment outcome in a wide range of
psychiatric disorders (Hatzenbueler & Pachankis, 2021), has been underinvestigated
in relation to anxiety disorder outcome. Considering that stigma also impacts quality
of life (Marcussen et al., 2010), another under investigated area of anxiety disorder
treatment, future research should prioritize targeting this important variable.
There remain significant gaps in the research on the benefits of existing
evidence-based interventions on several demographic groups, particularly people
of color and other underrepresented groups. While these are well-known limits,
strategies for improving representation in research that would in turn permit
greater generalization of treatment programs have not yet borne fruit. It is
expected that in the coming years more robust evidence-based treatment recom-
mendations may be made that address the needs of the widest swath of the
population.
58 Dean McKay

Useful Resources

Books for Professionals

• Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for
anxiety: Principles and practice (2nd ed.). Guilford.
• Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and
panic (2nd ed.). Guilford.
• Emmelkamp, P., & Ehring, T. (2014). The Wiley handbook of anxiety disorders. Wiley-
Blackwell.
• Olatunji, B. O. (2018). The Cambridge handbook of anxiety and related disorders.
Cambridge University Press.
• Sauer-Zavala, S., & Barlow, D.H. (2021). Neuroticism: A new framework for emotional
disorders and their treatment. Guilford.

Books for Clients and Consumers

• Bourne, E. J. (2020). The anxiety and phobia workbook. New Harbinger.
• Shannon, J. (2017). Don’t feed the monkey mind: How to stop the cycle of anxiety, fear and
worry. New Harbinger.

Organizations and Websites

• Anxiety and Depression Association of America (ADAA): www.adaa.org
• Association for Behavioral and Cognitive Therapies (ABCT): www.abct.org

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 5
Obsessive-Compulsive Disorder
Dean McKay

Obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric condition,

marked by intrusive and unwanted thoughts (obsessions) that provoke anxiety, and
that may be accompanied by compulsive behaviors designed to alleviate the obses-
sions. Estimates of prevalence vary, but generally range from 0.7% (Adam et al.,
2012) to 1.2% (Ruscio et al., 2010) over a one-year period. Early clinical descriptions
date back to Freud’s famous “Rat Man” (Freud, 1909).
The heterogeneity of OCD is illustrated by the wide variety of symptom presenta-
tions, and can be categorized roughly into the following dimensions: contamination
fear and washing rituals, obsessions (aggressive, sexual, religious, and somatic) and
checking compulsions, and symmetry obsessions and ordering/counting/repeating
compulsions (McKay et al., 2004; Abramowitz et al., 2005).1 Early descriptions of
OCD by Janet (1908) emphasized a perceptual component to the condition, one
marked by a sense of incompleteness for actions. Tests of incompleteness suggest
that it, along with a drive for harm avoidance, were associated with each dimension of
OCD (Taylor et al., 2014). The sense of incompleteness appears in the research as
reward insensitivity (discussed in Gruner & Pittenger, 2017).
This chapter covers treatment for OCD. It should be noted that some overlap in
treatment mechanisms apply to other diagnoses in the broader obsessive-compulsive
related disorders, the category of which OCD is part in the Diagnostic and Statistical
Manual (5th ed., text revision; 2022). These disorders share intrusive cognitions,
repetitive behaviors, or both. Theoretically, these disorders are unified by
a breakdown in behavioral inhibition (Fineberg et al., 2021). However, there have
been critiques of the shared neural mechanisms and logical consistency with under-
lying cognitive domains among these disorders (i.e., Abramowitz, 2018; Abramowitz
et al., 2009). Nonetheless, behavioral inhibition is relevant in the discussion of
treatments that follows in this chapter.
1
Hoarding was a symptom of OCD in earlier editions of the diagnostic manual, and was therefore an additional
dimension of OCD in the research cited. It was not listed here, as the current diagnostic manual lists hoarding as
a separate disorder.

64
 Obsessive-Compulsive Disorder 65

Etiology and Theoretical Underpinnings of Treatment

Etiological models of OCD derive from two major sources: biogenetic and cognitive-
behavioral. While the thrust of this chapter emphasizes psychosocial treatment – and
thus cognitive-behavioral approaches – the biogenetic model looms large over much
of the current evidence-based treatment models. This is because many treatment
guidelines stress the conjoint benefit of medication with treatment (i.e., Koran et al.,
2007; Anxiety and Depression Association of America, 2015). Further, recent
research has evaluated the role of neural stimulation methods (i.e., transcranial direct
stimulation; da Silva et al., 2019) in conjunction with cognitive-behavioral therapy
(CBT).
Before directly addressing etiological models based on CBT approaches to treat-
ment, OCD is compelling for its potential as a biologically based psychiatric condi-
tion. The aforementioned reward insensitivity is suggestive of a biological substrate,
considering the expressly psychophysiological modeling for behavioral inhibition
(Corr & Perkins, 2006), the apparent heritability (Mahjani et al., 2021), and seeming
brain localization (discussed in Stein et al., 2019). Despite the theoretical assertions
for a biological basis, definitive evidence has been elusive (Mahjani et al., 2021). To
be fair to the biological modeling of OCD, it is reasonable to consider that due to the
wide heterogeneity of the disorder, biological models cannot satisfactorily determine
unique neural or genetic features. To cite one illustration of how the heterogeneity
complicates determination of specific etiological factors, contamination obsessions
and washing rituals have been found to be a result of disgust as well as anxiety (i.e.,
Mancusi & McKay, 2021), whereas other symptom dimensions have prominent
anxiety without disgust (discussed in McKay et al., 2015). As a result of the compel-
ling notion of a neurobiological basis for OCD, much of the treatment research
literature includes a prominent role for medication or other neurobiological interven-
tions in conjunction with CBT, and thus few studies have completely isolated the
effects of CBT, either in total or for individual components. Interested readers are
directed to Pittenger (2017) for detailed coverage of neurobiological conceptualiza-
tions of OCD.
Cognitive-behavioral accounts of the etiology of OCD have been evolving,
beginning with purely behavioral descriptions that suggested compulsions arose
as a negatively reinforced behavior to alleviate obsessions (for a review, see
Clark, 2004). These early accounts were quickly confronted by the problem of
obsessions themselves, which are unlike other stimuli that are usually the source
of avoidance in negative reinforcement associated with fear learning. Specifically,
obsessions are purely internal events and required a different explanatory frame-
work. Based on these early observations, the first integrative cognitive-behavioral
account comes from Rachman and Hodgson (1980), who suggested that OCD is
essentially the result of the following cognitive vulnerabilities: dysphoric mood;
66 Dean McKay

stress; intolerance of certain thoughts; increased sensitivity to threat; and person-

ality variables, particularly neuroticism, introversion, and elevated emotionality.
This conceptualization also broadly expanded the scope of obsessional and com-
pulsive phenomena, and facilitated distinguishing the condition from obsessive-
compulsive personality.
Since the time of Rachman and Hodgson (1980), the conceptualization of
OCD has centered on how individuals with OCD differ from other people with
respect to their reactions to specific thoughts. Unwanted, intrusive thoughts are
a common experience in the general population (Freeston et al., 1991).
Individuals with OCD differ in their obsessional experiences from everyday
intrusive thoughts in the following ways: higher frequency, higher distress and
lower acceptability, guilt provoked by the thought(s), resistance when the
thought(s) occur, a sense of loss of control over the thought(s), intrusions
appraised as meaningful, substantial time with the thought(s) as focus of con-
sciousness, extensive concern over need to control the thought, and extensive
interference with activities (Clark, 2004).
The research described has led to the development of a more comprehensive
cognitive model of OCD. This conceptualization suggests that obsessions arise
from a specific set of dysfunctional beliefs. These beliefs are activated in response
to otherwise normal obsessions. One dysfunctional belief that has received consider-
able attention is an inflated sense of personal responsibility (Salkovskis, 1985).
Recent research has shown that inflated responsibility is indeed associated with
OCD, but is not a unique contributor to symptoms (McKay et al., 2014) and may be
more relevant for mild symptoms (Kim et al., 2016). Several other major dysfunc-
tional beliefs have been hypothesized to increase obsessional problems and associated
compulsive behavior. Among these are beliefs such as the over-importance of
thoughts (e.g., “My thoughts indicate something significant about me”), the need to
control thoughts, overestimation of threat, perfectionism, and intolerance for uncer-
tainty (see Taylor et al., 2007), and are relevant to the condition at all levels of severity
(Kim et al., 2016).
Recent additional conceptualizations of obsessional phenomena have focused on
the reasoning process that individuals with OCD undergo when appraising situations
that are associated with obsessions, rather than the content of obsessions themselves.
Termed the “inferential confusion” model, this has emerged to address the breakdown
in how individuals with OCD distrust their own perceptual experiences (O’Connor &
Robillard, 1995). Since this conceptual development, there have been several investi-
gations comparing a specific form of cognitive therapy based on this model to control
interventions (Julien et al., 2016). However, it has not yet undergone more rigorous
comparisons, nor are the distinctions with cognitive therapy yet empirically evalu-
ated. It is raised in this chapter to highlight an emerging potential direction in research
on OCD.
 Obsessive-Compulsive Disorder 67

Brief Overview of Treatments

The story of evidence-based treatment for OCD dates back to the mid-1960s. Aside
from Freud’s Rat Man, OCD was considered a chronic and untreatable condition
(Kringlen, 1965). Soon after that demoralizing assessment Meyer (1966) showed that
OCD could be treated by exposing clients to obsession-evoking stimuli followed by
blocking the associated rituals. This has come to be known as exposure with response
prevention (ERP), and is by far the most well-validated behavioral intervention for
OCD (discussed in McKay et al., 2015). The conceptual model for the mechanisms
underlying exposure therapy in general was described by Foa and Kozak (1986).
According to that model, it is considered necessary to evoke anxiety in order that
corrective processes take place. Since that time, the inhibitory learning model (ILM)
has emerged, which emphasizes new learning rather than anxiety evocation in order to
promote change. Interestingly, Meyer (1966) described ERP as altering expectancies
in clients; expectancy violations (and thus expectancy change) is a major component
of the ILM.
Since the emergence of ERP, cognitive interventions have emerged to either
augment behavioral interventions or to supplant them entirely. These interventions
build on the cognitive framework developed by Salkovskis (1985), and have been
expanded based on the identification of a core set of cognitions associated with OCD
(Obsessive Compulsive Cognitions Working Group, 2001). The extent that the unique
mechanisms for cognitive therapy can be isolated is limited, however, as treatment
often includes behavioral experiments, such as exercises that include exposure as
a means to provoke core cognitions (discussed in Abramowitz et al., 2005). Research
has demonstrated that cognitive change is an essential ingredient for substantial
symptom change (Woody et al., 2011), and, as a result, contemporary treatment for
OCD includes both cognitive and behavioral interventions, even if there is overlap in
the mechanisms between them.

Description of Treatment Packages

There are several treatment protocols for OCD. As noted, these can be roughly broken
down into either ERP or cognitive therapy. These will be considered separately,
although most specialists in OCD combine the two in evidence-based treatment as
part of routine care.
Numerous meta-analyses have been conducted that demonstrate ERP results in
large effect sizes in change when compared to control interventions. These meta-
analyses have considered ERP alone or in conjunction with cognitive therapy
(reviewed in Spencer et al., 2023). Additionally, cognitive interventions have been
shown to further moderate treatment efficacy (Ferrando & Selai, 2021), complicating
the extent that ERP may be considered a sufficient stand-alone treatment.
68 Dean McKay

Across all treatment packages that emphasize ERP, the common core includes:
developing a hierarchy of feared/avoided stimuli; practice in approaching these
stimuli, in vivo where possible; inclusion of imagery to enhance the exposure exer-
cises when conducted in vivo; and relapse prevention strategies. This process is akin
to that described for exposure treatment for anxiety disorders (see Chapter 4). The
response prevention arm of ERP is intended to continue exposure, since the central
function of rituals is to alleviate obsessional experiences and the associated emotional
arousal.
The model of cognitive therapy specifically developed for OCD is the accepted and
empirically supported approach, and is associated with large effect sizes when
compared to control interventions (Rosa-Alcázar et al., 2008). This is in direct
contrast to the original general cognitive therapy approach that includes direct
disputation of erroneous beliefs about harm. Recent conceptualizations suggest that
the more general cognitive therapy model is either benign or potentially harmful
(McKay, 2021) as the average OCD sufferer already recognizes the senselessness of
their symptoms.
The majority of research on core dimensions of beliefs in OCD has emerged from
the Obsessive-Compulsive Cognitions Workgroup (OCCWG, 2001). This consor-
tium of researchers developed a measure – the Obsessive-Beliefs Questionnaire
(OBQ-44; OCCWG, 2005) – that taps into six major cognitive dimensions: inflated
responsibility; overestimation of threat; perfectionism; intolerance of uncertainty;
importance of thoughts; and control of thoughts. Treatment programs have been
developed based solely on the cognitive model (i.e., Wilhelm & Steketee, 2006).
Across all cognitive therapy programs of treatment, the central focus is on how
individuals appraise situations, and then connect these appraisals to the core cognitive
dimensions considered theoretically associated with OCD.

Box 5.1 Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania,

and Excoriation

The publication of the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Association, 2013) included the development of
a new category of diagnoses: the Obsessive Compulsive Related Disorders (OCRDs).
This new category includes body dysmorphic disorder (BDD), which was formerly a
somatoform disorder, and trichotillomania, which was formerly an impulse control
disorder. The new category also includes a new disorder: hoarding disorder. Hoarding
was formerly a symptom of OCD, but extensive research showed that individuals whose
primary issue was hoarding behaviors exhibited significant differences in demographics,
functionality of symptoms, and other psychopathological signs (Pertusa et al., 2010). The
OCRDs also include a new diagnosis called excoriation (skin-picking) disorder, marked by
repetitive skin-picking.
 Obsessive-Compulsive Disorder 69

There are treatment protocols for each of the disorders in the OCRD category.
Treatment protocols for BDD emphasize cognitive-behavioral approaches for managing
body image and reducing compulsive behaviors typical for the disorder, such as mirror
checking and reassurance seeking regarding appearance (Wilhelm et al., 2012). Among
the OCRDs, treatment for BDD most closely resembles treatment for OCD, in that
exposure plays a prominent role in alleviating symptoms.
Treatment programs for trichotillomania (TM) center on habit reversal, a specific
behavioral procedure that involves training in competing responses that interfere with
the problematic repetitive behavior (reviewed in Farhat et al., 2020). In light of research
showing that TM is also associated with emotional regulation difficulties (Diefenbach
et al., 2008), specific interventions to target this aspect of functioning have been added
to programs of habit reversal (such as with dialectical behavior therapy; Keuthen et al.,
2011).
Treatment programs for hoarding disorder emphasize organization strategies,
attachment to objects, self-control methods to reduce acquisition of items, and skills for
managing emotional distress (Tolin et al., 2013). Among the OCRDs, hoarding disorder
is more likely to require intervention outside the office, given the extent to which
sufferers have pervasive difficulty managing their home environment.
The newest diagnosis in the DSM-5 – excoriation (skin-picking; dermatillomania)
disorder – has at this point limited specific treatment approaches. Treatment models for
this condition emphasize functional analysis for environmental and emotional
situations that result in urges to skin pick. As with TM, habit reversal programs have been
developed and shown to reduce symptoms of excoriation disorder (reviewed in
Lochner et al., 2017).

Overall Level of Research Support

Treatments involving ERP and CT together represent the standard of psychological
care for OCD (discussed in McKay et al., 2015). Evidence-based care for OCD
emphasizes the application of specialized CBT (i.e., ADAA, 2015), which collect-
ively represents a combination of ERP and CT. However, the extent to which
a clinician may rely more on ERP or more on CT hinges on several facets.
• General comfort with exposure-based therapy: There is an extensive body of work showing
that some clinicians are hesitant to conduct exposure-based treatments due to a range of
misconceptions about the approach (Deacon et al., 2013). To illustrate the extent to which
this hesitancy is germane to clinicians, the treatment text by Wilhelm and Steketee (2006)
emphasizes that with the program they describe, effective treatment can be delivered
without conducting exposure.
• Symptom dimension: The availability of in vivo stimuli that can be safely encountered for
exposure varies widely by symptom dimension. Individuals with washing rituals may more
readily have accessible stimuli for exposure (i.e., contact with ostensibly contaminated
surfaces), whereas individuals with intrusive thoughts of harm lack readily accessible
directly relevant cues.
70 Dean McKay

• Lag between exposure and likely feared outcome: When exposure is conducted, it is
predicted by the client that the feared outcome may occur in some discrete period of time
afterward. However, some obsessions have feared outcomes far in the future (i.e., contam-
ination fears about hepatitis, where illness may be many months after exposure) or post-
mortem (i.e., concerns about intrusive thoughts of blasphemy). These can pose significant
hurdles for clinicians in developing exposure procedures (discussed in McKay, Taylor, &
Abramowitz, 2010).
• Overvalued ideation: This is discussed in greater depth later, under “Other Variables
Influencing Treatment,” but deserves brief mention here. Some individuals with OCD
hold strong beliefs in the likelihood of aversive outcome when rituals are considered
essential. In some cases, these beliefs can come close to delusional in nature (Kozak &
Foa, 1994), and pose a significant barrier to implementing exposure.

In light of these considerations, the efficacy of CBT as a broader treatment program

can be considered efficacious. Overall, using the Chambless and Hollon (1998)
criteria for empirically supported treatments, the Society of Clinical Psychology
characterizes both ERP and CBT as being well-established for OCD (Society of
Clinical Psychology, n.d.). ERP is the only treatment to date that has been evaluated
using the Tolin, McKay et al. (2015) criteria, receiving a strong recommendation but
not yet a very strong recommendation (Tolin, Melnyk et al., 2015). Overall, consid-
erable expertise is required to make proper treatment decisions about how to develop
exposure methods and identify salient cognitive dimensions for individuals with OCD
while accounting for the myriad symptom presentations.

Credible Components of Treatments

Empirically supported treatment for OCD emphasizes combined ERP and CT. As
noted earlier, considering the overlap in methods for conducting exposure, whereby
feared outcomes may include elements that resemble cognitions, and CT, which may
include behavioral experiments that resemble exposure, it has been challenging to
isolate the effects of either ERP or CT in alleviating symptoms. Further complicating
the picture is the heterogeneity of symptoms, and hesitancy about conducting expos-
ure among some clinicians. Nonetheless, procedurally ERP and CT are different, and
training clinicians in the two methods requires clear delineation.

Aspects of Exposure
While discussed in the “Anxiety Disorders” chapter in this text (by the same author;
see Chapter 4), it is worth briefly discussing the contemporary model for exposure-
based treatment as it has undergone some changes in the past ten years. The original
model for exposure therapies emphasized activation of fear through engagement
specifically of neural structures that store memory for the emotional connection
 Obsessive-Compulsive Disorder 71

with the stimuli (Foa & Kozak, 1986). It is this model that many clinicians cited when
expressing concerns over conducting exposure therapy (discussed in Richard &
Gloster, 2006). While part of the expressed concerns by clinicians was that exposure
therapy increased the risk of drop-out, in the case of OCD this has not been observed
(Ong et al., 2016). While exposure therapy has always had behavior change as its
intended goal, the more recent inhibitory learning model (ILM; Craske et al., 2014)
explicitly focuses on change over emotional response. The methods for accomplish-
ing behavior change are broken into different strategies in the service of exposure. The
application of the ILM is, at this point, in the nascent stages of development when
applied to OCD, but may have promise (i.e., expectancy violations; Elsner et al.,
2022). Interested readers may consider formulations that translate the components of
ILM to applications for OCD (Jacoby & Abramowitz, 2016), and detailed discussions
of different components of the ILM are described in a series of articles (Frank &
McKay, 2019).

Cognitive Therapy
Behavioral Experiments
As noted earlier, some clinical guides emphasize CT without the need for ERP (i.e.,
Wilhelm & Steketee, 2006). Most of these same guides include specific exercises
aimed at providing clients with direct experiential tests of the cognitions that may
contribute to their obsessional concerns. These are termed “behavioral experiments”
(Bennett-Levy et al., 2004). While a small number of investigations have suggested
that cognitive therapy addresses the central mechanisms of change in OCD (i.e.,
Woody et al., 2011), the overall evidence remains that CT without corresponding ERP
is insufficient to produce lasting change in OCD treatment. It has been suggested that
the behavioral experiments that are central in CT form a type of exposure that
facilitates behavior change (Abramowitz et al., 2005). This view is consistent with
the modern ILM approach to exposure.
This is not to suggest that CT is unnecessary or superfluous in the treatment of
OCD. Research has suggested that the addition of CT to ERP produces the greatest
change in symptoms (Rector et al., 2019). Again, it should be emphasized, however,
that such additive investigations are limited by the extent to which CT expressly
involves an exposure component via behavioral exercises.

Cognitive Reappraisal
In addition to behavioral experiments, treatment for OCD involves targeting cognitive
distortions through systematic evidence-gathering in collaboration between therapist
and client. The belief domains described earlier, such as intolerance of uncertainty or
inflated responsibility, would be scrutinized for the extent that each may be valid in
72 Dean McKay

the daily life of the OCD sufferer, with between-session exercises aimed at finding
disconfirming evidence (Salkovskis, 2007).

Approaches for Youth

As with adult treatment for OCD, the emphasis for treatment with children is on ERP
and, where suitable, CT. Extensive multisite investigations of the efficacy of CBT,
broadly defined, have demonstrated significant symptom reduction in children (i.e.,
the Pediatric OCD Treatment Study Team [POTS, 2004; Franklin et al., 2011]).
Treatment programs for OCD in children emphasize developmental features in
addition to highlighting exposure for feared situations in order to promote symptom
reduction. As a result, in younger children there are added treatment components that
address emotion regulation and significant family and caregiver components to
alleviate disruptive behavior that children may exhibit when faced with otherwise
fear-evoking stimuli (Freeman et al., 2014). Broad, multicomponent treatment
models – including approaches for groups, school settings, and for complex symptom
presentations – are available (Storch et al., 2018).

Other Variables Influencing Treatment

Assessment and Diagnosis
There is an extensive array of assessment tools for evaluating severity and symptom
dimensions of OCD (Taylor et al., 2020). While there are numerous measures, two
major instruments have been most frequently applied for assessing symptom dimen-
sions and associated severity. The Yale–Brown Obsessive-Compulsive Scale
(Goodman et al., 1989) has been extensively evaluated for its psychometric properties
and, while there are limitations (such as the item assessing resistance to obsessions), it
is widely considered the “gold standard” for clinician-administered severity assess-
ment (Rapp et al., 2016).
The other major measure is a self-report scale: the Obsessive-Compulsive
Inventory-Revised (OCI-R; Foa et al., 2002). This scale can be broken into subscales
that evaluate dimensions of OCD based on washing, checking, ordering, obsessing,
neutralizing, and hoarding. Severity benchmarks have been developed for this scale
(Abramovitch et al., 2020), and a recent revision to the measure has been completed
that provides benchmarks for severity based on a subset of items that eliminates
hoarding (as that is a separate disorder in DSM-5-TR) and neutralizing (as that is
a symptom management strategy rather than a symptom per se) (Abramovitch et al.,
2021).
It should be noted that should other symptom dimensions appear relevant, or
clinical assessment suggests that other mechanisms are involved (such as the sense
 Obsessive-Compulsive Disorder 73

of incompleteness), then additional assessment tools may be necessary to capture the

full scope of symptom expression in OCD. These are described in detail in Taylor
et al. (2020).
Although OCD is often described as a “fear,” research over the past twenty years
has suggested a prominent role for disgust as well. Disgust remains an understudied
emotion (McKay, 2017). At its core, disgust protects from ingestion of harmful
substances, but it is also more general in protecting from any illness or disease
state. As a result, in the specific case of contamination fear and washing rituals,
concerns over “spreading” of putative toxins forms the core aspect of avoidance
behavior. Experimental research has shown that the perceived contaminating force
can remain in place for up to 12 steps removed from the original source among
individuals with this symptom dimension of OCD – a significantly greater degree than
for individuals with other anxiety disorders or nonanxious controls (Tolin et al.,
2004). Recent conceptualizations have expanded this model to consider the unique
blend of disgust and fear, specifically over the prospect of contaminants penetrating
the skin, with individuals with elevated contamination fear showing greater avoidance
of stimuli perceived to have a high propensity for skin penetration (e.g., blood worms)
compared to individuals with high levels of anxiety without contamination fear and
nonanxious controls (Mancusi & McKay, 2021). This is salient as it is less clear that
disgust responds to exposure in the same way that fear does, and may call for different
conceptualizations for intervention (Mason & Richardson, 2012).
Kozak and Foa (1994) laid out a conceptual model for overvalued ideation (OVI) in
OCD. This framework places obsessions on one end of a dimension that goes through
to delusions, with OVI closer to the delusional end of the spectrum. When present,
OVI is considered an impediment to treatment using ERP and other cognitive
methods, given that the sufferer holds the conviction that their obsessions pose
a genuine risk, or that the compulsive behavior is essential. At the present time,
there are no clear treatment guidelines for addressing OVI in conjunction with OCD.

Comorbidity
In addition to being highly heterogeneous, OCD is also marked by commonly occur-
ring comorbid conditions. There are two in particular that stand out for complicating
symptom management.
While it is not uncommon for depressed mood to occur secondary to severe
symptoms of OCD, when depression exists as a distinct comorbid condition it has
long been recognized as a complicating aspect of treatment (Grabill et al., 2008). One
aspect which explains this complication is that when conducting exposure treatment,
depressed mood interferes with emotional activation and associated behavior change.
On the other side of this challenge, implementation of interventions aimed expressly
at depressed mood runs into difficulty due to the avoidance associated with OCD.
74 Dean McKay

Recent research suggests that the inclusion of behavioral activation to target depres-
sion may overcome this clinical challenge (Wheaton & Gallina, 2019).
Some neurobiological models of OCD emphasize the involvement of the basal
gaglia, with some recent reviews supporting this association (Pearlman et al., 2015).
Similarly, tic disorders have been associated with dysfunction in the basal ganglia
(discussed in Bronfeld & Bar-Gad, 2013). This putative neural overlap has resulted in
observed cases of tics comorbid to OCD, or even subtypes of OCD termed “Tourettic
OCD” (Mansueto & Keuler, 2005). This complex symptom presentation poses unique
challenges in treatment as tics are often exacerbated by stress, which is induced as part
of ERP. At the present time there are primarily case studies and conceptual models for
how to address this complex symptom presentation, but little in the way of any
systematic research.

Demographics
A significant limitation in the research into treatment for OCD is that the
majority of studies undersample underrepresented groups. This problem has
been known for some time (Williams et al., 2010), but has yet to be fully
addressed. As a result, it is likely that many individuals from underrepresented
groups are misdiagnosed. Indeed, OCD is frequently misdiagnosed (Stahnke,
2021), leading to inappropriate care. Misdiagnosis with more severe psychiatric
conditions is common among underrepresented groups (i.e., African Americans;
Williams et al., 2012).
Gender also plays a significant role in treatment efficacy for OCD. While OCD is
slightly more common among females, males tend to report earlier age of onset and
higher rates of intrusive blasphemous thoughts (Mathes et al., 2019). As noted earlier,
blasphemous thoughts pose a unique challenge given the lag between exposure
exercises and perceived aversive outcomes. However, there has been limited research
into treatment outcome differences among genders.

Medication
The vast majority of individuals with OCD have likely been prescribed psychiatric
medications, and thus treatment trials often include individuals who have been on one
or more medication or have tried multiple courses of medications. The general
“clinical wisdom” is that medication in conjunction with CBT is the best course of
action (i.e., ADAA or American Psychiatric Association treatment guidelines).
However, it has been observed that the incremental gain for medication is slight
when added to CBT for OCD in adults (Skapinaki et al., 2016) and children (Tao et al.,
2022). An overview of medication managements strategies for OCD is available in
McKay (2019).
 Obsessive-Compulsive Disorder 75

Conclusion
Research into treatment for OCD has expanded significantly in the past forty
years, and there is now a well-developed set of interventions for the condition.
The two major psychosocial interventions, ERP and CT, together form
a comprehensive set of methods for addressing a large proportion of symptoms
that are commonly experienced among OCD sufferers. The marked heterogen-
eity of the condition has been emphasized in this chapter, though, and thus
treatment for OCD calls for a high degree of expertise to understand the nuances
of the disorder. Aside from high variability in symptom dimensions, there are
commonly occurring complications such as comorbid depression or OVI, and
additional emotional dimensions (i.e., disgust) that may not respond to exposure-
based interventions. Further, the majority of the treatment research is best
generalized to majority white populations, and thus careful considerations need
to be taken when developing treatment for members of underrepresented groups
and people of color.

Useful Resources

• Anxiety & Depression Association of America Clinical Practice Guidelines: https://adaa

.org/resources-professionals/practice-guidelines-ocd
• International Obsessive-Compulsive Disorder Foundation: www.iocdf.org
• Mental Health America: www.mentalhealthamerica.net/conditions/ocd
• National Institute of Mental Health Fact Sheets: www.nimh.nih.gov/health/topics/obses
sive-compulsive-disorder-ocd/index.shtml
• Springer, K. S., & Tolin, D. F. (2020). The big book of exposures: Innovative, creative, and
effective CBT-based exposures for treating anxiety-related disorders. New Harbinger.

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 6
Posttraumatic Stress Disorder
Carmen P. McLean and Eve A. Rosenfeld

Since acute stress disorder and posttraumatic stress disorder (PTSD) were first
codified in the Diagnostic and Statistical Manual for Mental Disorders (DSM-
III) in 1980, our understanding of how to treat these posttraumatic stress reac-
tions has expanded considerably, and there are now a number of evidence-based
psychotherapy (EBP) options available. The current (DSM-5-TR) criteria for
PTSD requires exposure to a traumatic event, defined as actual or threatened
death, serious injury, or sexual violence, as well as symptoms from each of four
clusters: re-experiencing symptoms (e.g., intrusive distressing memories), avoid-
ance symptoms (e.g., avoiding thoughts related to the trauma), alterations in
cognitions and mood symptoms (e.g., feeling detached or estranged from others),
and arousal symptoms (e.g., hypervigilance). Symptoms must be present for
more than one month after trauma exposure; prior to one month, a diagnosis
of acute stress disorder may be appropriate.
Exposure to traumatic events is relatively common. However, most individ-
uals who experience trauma recover on their own, without any formal interven-
tion, in the weeks and months following the traumatic event (e.g., Bonanno
et al., 2015). Nevertheless, a substantial minority of those exposed to trauma
develop acute stress disorder and go on to develop PTSD. Epidemiological
research has found a lifetime prevalence for PTSD of 8.5% for women and
3.4% for men in the United States (McLean et al., 2011), although the rates of
PTSD are higher among certain groups, such as military personnel (Institute of
Medicine, 2014; Tanielian et al., 2008). In the absence of effective treatment,
PTSD can be a chronic and disabling disorder associated with significant distress
and overall functional impairment (e.g., Kachadourian et al., 2019). Most indi-
viduals with PTSD also meet criteria for at least one additional psychiatric
diagnosis, most commonly depressive disorders, anxiety disorders, and substance
use disorders (Kessler et al., 2005).

81
82 Carmen P. McLean and Eve A. Rosenfeld

Etiology and Theoretical Underpinnings of Treatment

The most prominent theories of PTSD development can be defined broadly as
cognitive-behavioral, with each having a slightly different focus. Behavioral
theories are rooted in learning and conditioning models, including both classical
and operant conditioning. Mowrer’s (1960) influential two-factor theory purports
that classical conditioning can explain the development of fear reactions to
previously neutral stimuli that were paired with the traumatic event, which
then elicit fear reactions at subsequent presentations. Traumatic reactions can
spread to stimuli that are less clearly related to the traumatic event through the
process of generalization. Operant conditioning explains how negative reinforce-
ment of avoidance can maintain fear reactions by limiting opportunities for
extinction – the process by which individuals learn that conditioned stimuli no
longer signal threat.
Schema theories and cognitive theories focus on core assumptions or beliefs
guiding the interpretation of new information. For example, Janoff-Bulman (1989)
proposed that trauma disrupts core assumptions about the world as generally benevo-
lent and meaningful and the self as intrinsically worthy. As a result of this disruption,
trauma survivors either assimilate the experience into existing core assumption (e.g.,
blaming oneself for the trauma to protect the belief in a just world), which could
increase risk for PTSD, or change their core assumption to accommodate the trauma
(e.g., the world is not always benevolent). Early research among trauma survivors
found that beliefs about safety, trust, power and control, esteem, and intimacy are
particularly susceptible to disruptions after a trauma (Janoff-Bulman, 1985; McCann
et al., 1988). Building on this work, as well as Beck et al.’s (1979) cognitive theory,
Resick and Schnicke (1993) proposed that PTSD can develop when disruptions in
beliefs keep trauma survivors “stuck” in distress, and that treatment should therefore
involve identifying “stuck points” (i.e., inaccurate thoughts) and challenging them
through Socratic questioning with the goal of developing accurate, balanced perspec-
tives on the trauma. Ehlers and Clark’s (2000) cognitive model proposed two key
factors that interact to promote the development and maintenance of PTSD: (1)
trauma-related beliefs or appraisals about threat (e.g., “the world is dangerous”) and
(2) the fragmented nature of the traumatic memory that does not incorporate other
autobiographical memories. Consistent with this theory are findings that PTSD is
associated with maladaptive appraisals of the trauma (e.g., Bryant & Guthrie, 2007)
and fragmented trauma narratives (e.g., Amir et al., 1998). Recall of the fragmented
memory elicits distress and promotes threat appraisals, which in turn biases recall of
the trauma memory in ways that further reinforce threat appraisals. It follows that
cognitive therapy focuses on correcting beliefs and assumptions thought to underlie
PTSD and elaborating the trauma memory and integrating it into the context of the
survivor’s life narrative.
 Posttraumatic Stress Disorder 83

Emotional processing theory (Foa & Kozak, 1985) is based on Mowrer’s (1960)
theory and bioinformational models of fear (e.g., Lang, 1977). Emotional processing
theory proposed that trauma-related emotions are represented in memory as cognitive
structures that include information about stimuli, responses, and their meaning, which
are interrelated such that inputs matching any part of the structure activate the entire
structure. Pathological fear structures are characterized by over-generalization and
excessive responding to safe stimuli. Consistent with this notion are findings of
attentional biases to a wide range of threat cues among individuals with PTSD (e.g.,
Harvey et al., 1996). This theory proposes that activation of the fear structure (e.g.,
through approaching trauma memories) in the absence of anticipated harm promotes
recovery via disconfirmation of the pathological elements of the fear structure.
Inhibitory learning theory (Craske et al., 2008) is based on learning paradigms
showing that return of fear is common following extinction (Bouton, 1993). After
successful extinction or exposure therapy, associations between the trauma stimuli
and threat remain and compete with the newly formed associations between the
trauma-related stimuli and safety. When trauma-related stimuli are encountered, the
time since extinction/exposure and contextual cues determine which of these two
associations is activated.

Brief Overview of Treatments

A number of psychotherapies for PTSD have been found efficacious in randomized
controlled trials (RCTs) relative to various control conditions. The most consistently
supported treatments are referred to as “trauma-focused psychotherapies.” These
treatments directly target thoughts, feelings, and/or memories of the worst traumatic
event. Trauma-focused psychotherapies include exposure therapies such as prolonged
exposure therapy (Foa et al., 2019); cognitive approaches such as cognitive process-
ing therapy (CPT; Resick et al., 2017) and cognitive therapy (Ehlers et al., 2003); and
other types of cognitive-behavioral therapy (CBT; e.g., Blanchard et al., 2003).
Trauma-focused psychotherapies for PTSD are CBTs: they are based on principles
of learning theory and/or cognitive theory and focus on changing maladaptive patterns
of behaving and/or thinking.
Results from several large meta-analyses and systematic reviews indicate that
trauma-focused psychotherapies are associated with large treatment effects. For
example, an analysis by Watts et al. (2013) of 112 RCTs found that cognitive therapy
and exposure therapy were associated with the largest effects. Another meta-analysis
(Cusack et al., 2016) included 64 RCTs and graded the overall strength of the
evidence (SOE) for each treatment based on information about risk of bias among
the relevant studies and the consistency, directness, and precision of the evidence
supporting a given treatment. Based on this analysis, Cusack et al. concluded that
prolonged exposure, cognitive therapy, and CPT had the highest SOE. Other CBT
84 Carmen P. McLean and Eve A. Rosenfeld

Box 6.1 The Controversy Over Eye Movement Desensitization and Reprocessing

Eye movement desensitization and reprocessing (EMDR; Shapiro & Maxfield, 2002) is
a controversial trauma-focused treatment. EMDR has been found efficacious, with
effect sizes that are comparable to other trauma-focused treatments (Lewis et al., 2020;
McLean et al., 2022; Watts et al., 2013), although there is some evidence of greater risk
of bias among EMDR studies (Cusack et al., 2016; McLean et al., 2022). EMDR includes
exposure to trauma-related images accompanied by a “bilateral stimulation” task, such
as following the therapist’s hand moving back and forth with the patient’s eyes. The
major points of contention are whether the revisiting of the trauma imagery (i.e.,
exposure) by itself is the primary driver of change in EMDR, and whether, as originally
theorized (Shapiro, 1989), the concurrent bilateral stimulation component impacts
outcomes (Rosen & Davison, 2003). Dismantling studies (Cahill et al., 1999; Pitman
et al., 1996; Sanderson & Carpenter, 1992), reviews (Cahill et al., 1999), and meta-
analyses (Davidson & Parker, 2001) found no evidence supporting the clinical value of
eye movements. A meta-analysis by Lee and Cuijpers (2013) found that effect sizes
were larger when eye movements were used. However, this study included mainly
experimental studies with healthy participants and used subjective process measures
as outcomes. A subsequent meta-analysis focused on PTSD clinical trials found no
evidence supporting the eye movement component (Cuijpers et al., 2020).
Interestingly, Sack et al. (2016) found that visual attention on the therapist produced
superior treatment outcomes than no instruction on attentional focus, and the
induction of eye movements by following the therapist’s moving hand did not offer an
advantage compared to visually fixating on a nonmoving hand. The necessity of the
bilateral stimulation component of EMDR remains controversial (Jeffries & Davis, 2013;
Schubert & Lee, 2009) and higher-quality studies are necessary in order to resolve this
controversy (Cuijpers et al., 2020). For more about the EMDR controversy, see Rosen
and colleagues (2023).

packages were associated with a moderate SOE. The most recent meta-analysis of
PTSD psychotherapies (Lewis et al., 2020) included 114 RCTs and concluded that
there was robust evidence to support the efficacy of trauma-focused CBTs, including
CPT, prolonged exposure, and cognitive therapy.
Consistent with these findings, Clinical Practice Guidelines (CPGs) based on
systematic reviews of the available research all recommend trauma-focused psycho-
therapy as first-line intervention for PTSD. Five major CPGs for PTSD (see Hamblen
et al., 2019 for a summary) have been published by workgroups at the American
Psychological Association (APA, 2017), the International Society for Traumatic
Stress Studies (ISTSS, 2018), the National Institute for Health and Care Excellence
(NICE, 2018), the Phoenix Australia Centre for Posttraumatic Mental Health (2013),
and the Department of Veterans Affairs and Department of Defense (VA/DoD, 2017).
Although some CPGs recommend trauma-focused psychotherapy in general while
 Posttraumatic Stress Disorder 85

others name specific protocols (e.g., APA recommends CBT, prolonged exposure,
CPT, and cognitive therapy), all five CPGs give their strongest recommendation to
PE, CPT, and trauma-focused CBT.

Credible Components of Treatments

Psychoeducation
Psychoeducation is a common component of trauma-focused interventions in which
a mental health provider delivers relevant, up-to-date information about trauma and
posttraumatic stress (Brouzos et al., 2022). Psychoeducation may be delivered pas-
sively (e.g., leaflets, informational websites) or actively (e.g., therapist-guided activ-
ities; Donker et al., 2009). Psychoeducation has been used as a stand-alone
intervention; however, a meta-analysis found that stand-alone psychoeducation inter-
ventions do not significantly affect PTSD symptoms, nor do they differ from treat-
ment-as-usual (Brouzos et al., 2022). In contrast, psychoeducation is a fundamental
component of PTSD treatment when used in combination with other components
(Whitworth, 2016). Within trauma-focused treatment, psychoeducation focuses on
increasing comprehension of common reactions to trauma, normalizing reactions to
trauma, building rapport, highlighting the role of avoidance and/or unhelpful beliefs
in perpetuating PTSD symptoms, and providing a rationale for therapeutic skills and
tasks (Brouzos et al., 2022; Whitworth, 2016). Psychoeducation can be integrated
throughout treatment for PTSD, but it may be particularly crucial in the early stages of
treatment in order to stimulate motivation and buy-in (Phoenix, 2007). Indeed,
psychoeducation is highly acceptable to (Brooks et al., 2021) and valued by patients,
who report high satisfaction, improvements in awareness of treatment options, greater
optimism, and increased motivation for treatment (Gray et al., 2004). This may be
especially important in trauma-focused treatment, as patients are asked to confront
trauma reminders and/or challenge beliefs that may serve a psychologically protective
function. When patients considered dropping out of trauma-focused treatment,
a major contributing factor in their decision to continue treatment was belief in the
treatment rationale (Hundt et al., 2017), highlighting the importance of psychoeduca-
tion in facilitating buy-in and promoting treatment retention. Psychoeducation also
reduces stigma surrounding PTSD and seeking help for it (Gould et al., 2007).

Homework
In PTSD treatment, “homework” refers to structured, therapeutic activities completed
between sessions and reviewed in session (Kazantzis et al., 2010). The purpose of
therapy homework is to facilitate the rehearsal of therapeutic skills and the general-
ization of learning to new settings (Cummings et al., 2014; Mausbach et al., 2010).
While most practicing psychologists use homework with their clients (Kazantzis &
86 Carmen P. McLean and Eve A. Rosenfeld

Deane, 1999), it is viewed as most integral to CBT (Cooper et al., 2017; Detweiler &
Whisman, 1999). Indeed, the majority of trauma-focused interventions for PTSD
involve homework as a core component. Additionally, the majority of patients view
homework positively and find it beneficial (Fehm & Mrose, 2008). Meta-analyses
have demonstrated that homework adherence (i.e., completion of agreed upon home-
work) is associated with positive outcomes in CBT (Kazantzis et al., 2000; Mausbach
et al., 2010). This is also true for trauma-focused treatment specifically: homework
adherence is associated with enhanced outcomes for both CPT (Stirman et al., 2018)
and prolonged exposure (Cooper et al., 2017). Homework facilitates rehearsal of
skills and generalization of learning to new settings. For instance, in prolonged
exposure, listening to recordings of in-session imaginal exposures for homework
facilitates between-session extinction (Brown et al., 2019), which is associated with
positive treatment outcomes (Rupp et al., 2017). Quality of homework also appears to
be important for outcomes (Kazantzis et al., 2016). As such, clinicians should
reinforce not only homework completion but high-quality homework completion
(e.g., “I can see you put a lot of effort into this worksheet”; “I’m impressed that you
stuck with that exposure without using any safety behaviors”). While it is difficult to
parse the effects of homework from those of other components (e.g., in prolonged
exposure, in vivo exposures are conducted entirely as homework assignments),
homework adherence is consistently linked with enhanced outcomes. Thus, home-
work is a crucial component of most trauma-focused treatments used to facilitate and
reinforce therapeutic learning

Exposure Therapy
Exposure is one of the most commonly used components in effective PTSD treat-
ments. Exposure therapy derives directly from learning theories and can be con-
sidered a clinical analogue for extinction learning paradigms. Because PTSD is
characterized by behavioral and cognitive avoidance, exposure involves repeatedly
approaching feared thoughts, images, objects, situations, or activities in the absence of
the expected negative outcome, in order to reduce pathological fear, anxiety, and other
symptoms. There are two types of exposure that are used in treatments for PTSD.
The most common type is called “imaginal exposure,” which involves revisiting the
memory of the traumatic event in one’s imagination and, typically, recounting the
events that occurred. Early studies of exposure therapy for PTSD used a variation of
imaginal exposure known as “implosive” (or flooding) therapy (Boudewyns & Hyer,
1990; Keane et al., 1989), in which clients were guided through graduated imaginal
exposure to trauma-related scenes. Some exposure therapy protocols also include
a second type of exposure called “in vivo exposure,” which involves approaching
trauma-related situations or stimuli in real life. Early studies of implosive therapy
informed the development of prolonged exposure therapy (Foa et al., 2019), the most
 Posttraumatic Stress Disorder 87

well-studied exposure protocol. Prolonged exposure includes both imaginal and

in vivo exposures. Other exposure-based therapies for PTSD include narrative expos-
ure therapy (NET; Schauer et al., 2011), written exposure therapy (WET; Sloan &
Marx, 2019), and some trauma-focused CBT protocols (e.g., Blanchard et al., 2003).
Exposure therapies also include psychoeducation and typically, but not always
(notably, WET), also include homework.
Many PTSD treatments are comprised of multiple components that are also used as
stand-alone therapies. This makes the distinction between dismantling research,
augmentation research, and comparative efficacy research somewhat unclear.
Regardless, all of these study designs aim to answer the question of which treatment
components matter most for therapeutic change. For example, several studies have
tested combinations of exposure therapy and cognitive therapy, which are both
components of trauma-focused CBT protocols but are also stand-alone treatments
for PTSD. Findings from these studies (Bryant et al., 2003; Foa et al., 2005; Marks
et al., 1998; Paunovic & Öst, 2001) generally show that adding cognitive restructuring
does not improve outcomes in the context of exposure therapy for PTSD. An excep-
tion to this are findings from Bryant et al., (2008) showing that cognitive restructuring
and exposure led to superior outcomes than three exposure alone conditions: imaginal
exposure, in vivo exposure, and both imaginal and in vivo exposure. It is worth noting
that in prolonged exposure, imaginal exposure is followed by “processing,” which
involves discussing the experience of revisiting the trauma memory with a focus on
new learning and changed beliefs or perspectives. Processing is not as structured or
directive as cognitive restructuring, but the two techniques are conceptually similar
and share similar therapeutic goals. Thus, it is possible that some sort of elaboration of
the learning that occurs during exposure is beneficial, and that that this is couched as
processing of the imaginal exposure in some protocols and as cognitive restructuring
in others. It may be that combining exposure and cognitive approaches does not
improve outcomes because they share the same underlying therapeutic mechanisms.
Possibly, lower-order associative processes like extinction learning or inhibitory
learning occur, in varying degrees, in both exposure and cognitive therapies, affecting
higher-order cognitive processes such as changes in trauma-related beliefs, which in
turn supports subsequent associative learning (see Cooper et al., 2017; LeDoux,
2014). At present, we know very little about the mechanisms underlying effective
PTSD treatment.
Bryant et al. (2008) can also be considered a dismantling study of protocols that
combine imaginal and in vivo exposure. Bryant et al. found that imaginal exposure,
in vivo exposure, and their combination were all effective (and inferior to the
condition combining imaginal and in vivo exposure with cognitive restructuring).
Thus, although Devilly and Foa (2001) argued that it is important to integrate in vivo
and imaginal exposure, Bryant et al.’s findings suggest that combining in vivo and
imaginal exposure may not be necessary, as the in vivo and imaginal exposure
88 Carmen P. McLean and Eve A. Rosenfeld

conditions both did as well as the condition that combined them. To date, very little
research has examined differential responses to imaginal exposure and in vivo
exposure.
Exposure appears to be a robust and flexible treatment approach in that it has been
found efficacious when delivered in a wide range of formats and delivery tempos. For
example, imaginal exposure is effective when the trauma memory is recounted
verbally (e.g., Foa et al., 2005) or through writing (e.g., Sloan et al., 2018), imple-
mented for longer (~40 minutes) or shorter periods (~20 minutes; e.g., Foa et al.,
2022), and when patients recount the trauma memory from their imagination or
through virtual reality (e.g., Reger et al., 2019). Exposure therapy is effective when
delivered once-weekly (e.g., Foa et al., 2013), twice-weekly (e.g., Foa et al., 1999),
daily (e.g., Foa et al., 2018), or in intensive outpatient programs (e.g., Rauch et al.,
2021), and delivered in-person or via video telehealth (e.g., Acierno et al., 2017).
There is also preliminary evidence for web-based delivery (McLean et al., 2021).

Cognitive Therapy
Cognitive therapy is another commonly used component in effective PTSD
treatments. Because disruptions in beliefs can keep trauma survivors “stuck” in
distress, cognitive therapies aim to identify inaccurate or unhelpful cognitions
about the trauma and the survivor’s reaction to the trauma and challenge them
through Socratic questioning. The two most well-supporting treatments for PTSD
that focus on cognitive therapy are CPT (Resick et al., 2017) and the cognitive
therapy protocol developed by Ehlers and Clark (2000). CPT derives from
cognitive (e.g., Beck et al., 1979) and schema theories (e.g., Janoff-Bulman,
1989). Ehlers and Clark (2000) later developed a cognitive model of PTSD and
a corresponding treatment protocol based on this model. Both involve identifying
inaccurate or unhelpful beliefs and challenging them, using Socratic questioning
with the goal of arriving at more accurate and balanced conclusions. Both
treatments also include common CBT components of psychoeducation and home-
work. CPT also involves strategies to increase awareness and acceptance of
natural trauma-related emotions (e.g., sadness, anger), identify cognitive distor-
tions, and explore trauma-related themes (e.g., safety, trust) via cognitive restruc-
turing. In addition, CPT originally included a written exposure component.
Cognitive therapy typically includes some form of exposure (imaginal and/or
in vivo), although these are conceptualized as techniques to promote elaboration
and integration of the trauma memory and are integrated with cognitive restruc-
turing techniques.
One of the first studies of CPT was a dismantling study to examine the
relative efficacy of the theorized active elements of CPT. In this study, Resick
and colleagues (2008) compared the full CPT protocol (which included written
 Posttraumatic Stress Disorder 89

exposure) with a written exposure only condition and a cognitive therapy only
condition. All three treatments were found to be effective in reducing PTSD
symptoms; however, participants in the cognitive therapy only condition showed
more improvement than did those in the written exposure only condition. These
findings informed a revision to the CPT protocol to designate the written account of
the trauma as optional versus standard. Sloan et al. (2018) later compared 5 sessions
of written exposure therapy (WET) to 12 sessions of CPT (including written
exposure) and found WET noninferior to CPT.

Approaches for Youth

Treatment guidelines for children and adolescents are less consistent than those for
adults. However, all guidelines recommend trauma-focused CBT (TF-CBT; Cohen &
Mannarino, 2017) as a first-line approach. TF-CBT typically incorporates a caregiver in
treatment (e.g., a nonperpetrating parent) and includes psychoeducation, emotion
regulation and coping skills training, cognitive processing/restructuring, imaginal
exposure, and in vivo exposure. TF-CBT demonstrated effectiveness for children
impacted by a wide range of traumatic events and in children as young as preschool
age (e.g., Scheeringa et al., 2011). PTSD treatments designed for adults have also been
modified for use with younger populations, including prolonged exposure (e.g., Foa
et al., 2008), cognitive therapy (Perrin et al., 2017), and NET (e.g., Ruf et al., 2010).
Consistent with the adult literature, research has found that exposure-based CBT leads
to comparable PTSD change, as does trauma-focused cognitive therapy at posttreatment
(Nixon et al., 2012) and up to one year posttreatment (Nixon et al., 2017).

Other Variables Influencing Treatment

Assessment and Diagnosis
The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013b) is a widely used
self-report measure of PTSD symptoms that mirror the DSM-5 symptom criteria for
PTSD. The PCL-5 has excellent psychometric properties (e.g., Bovin et al., 2016).
A cut-off score of 31–33 is suggested for identifying probable PTSD (Bovin et al.,
2016). Additional well-validated self-report measures include the Impact of Events
Scale-Revised (IES-R; Weiss & Marmar, 1996) and Posttraumatic Stress
Diagnostic Scale for DSM-5 (PDS-5; Foa et al., 2016). An important issue for
assessing PTSD is the need to link the symptoms to a Criterion A traumatic event
(i.e., “index” event). For this reason, self-report measures of PTSD symptoms that
do not include an assessment of trauma exposure should be administered along with
a measure of Criterion A trauma, such as the Life Events Checklist (LEC-5;
Weathers et al., 2013a) whenever the client’s index event (i.e., the worst/most
bothersome traumatic event) is not known. Repeated administration of symptom
90 Carmen P. McLean and Eve A. Rosenfeld

rating scales (e.g., administering the PCL-5 at every other session) is recommended
to inform shared clinical decision-making about the helpfulness of treatment and the
need to terminate or consider alternate treatment (i.e., measurement-based care).
Assessing key associated constructs, such as negative trauma-related cognitions
(Foa et al., 1999; Wells et al., 2019), may also be useful to guide treatment planning.
Structured diagnostic interviews such as the Structured Clinical Interview for
DSM-5 Axis I Disorders, PTSD Module (SCID-5; First et al., 2016) and the
Clinician Administered PTSD Scale for DSM-5 (Weathers et al., 2018) are recom-
mended and common in clinical research settings. The CAPS-5 is considered the
gold-standard interview measure of PTSD and yields comprehensive information
about diagnostic status and symptom severity. PTSD is a heterogenous disorder
comprised of behavioral, emotional, and cognitive symptoms. Some of these symp-
toms overlap with other disorders, and PTSD is associated with a high rate of
psychiatric comorbidity (Kessler et al., 2005). Thus, it is important to evaluate the
presence of other commonly co-occurring disorders.
When the onset of PTSD symptoms is delayed by six months or longer from the
traumatic event, PTSD is diagnosed with a delayed onset specifier. There is no
evidence to suggest that a delay in symptom onset impacts treatment prognosis.
When less than one month has passed since the traumatic event, a diagnosis of
acute stress disorder may be appropriate. Implementing brief trauma-focused psycho-
therapy within the first few weeks or months following a traumatic event can promote
recovery among those experiencing significant PTSD symptoms (e.g., Roberts et al.,
2019).
Complex PTSD, which is now included in the International Classification of
Diseases, version 11 (ICD-11; WHO, 2022), comprises the core symptoms of
PTSD, as well as three symptom groups of affective, relationship, and self-concept
changes (Maercker, 2021). Trauma-focused psychotherapies, including CBT and
exposure therapy, have been found efficacious for complex PTSD (Karatzias et al.,
2019). In the past, a “phase-based” approach was recommended for complex PTSD,
wherein a stabilization phase precedes a trauma-focused phase (e.g., Benham, 1995;
Fisher, 1999). Goals of the stabilization phase include ensuring the patient’s safety by
improving self-regulation and interpersonal skills. However, evidence does not sup-
port this recommendation and guidance has shifted away from it, given that it
unnecessarily delays implementation of evidence-based components (Bicanic et al.,
2015; De Jongh et al., 2016).

Comorbidity
As noted previously, PTSD is associated with very high rates of psychiatric
comorbidity. Fortunately, trauma-focused PTSD treatments remain efficacious
when comorbid disorders are present, even without major adaptations for some
 Posttraumatic Stress Disorder 91

disorders. For example, prolonged exposure has been found effective among
patients with comorbid major depressive disorder (e.g., Hagenaars et al., 2010)
and mild to moderate traumatic brain injury (e.g., Ragsdale & Voss Horrell,
2016). Moreover, symptoms of comorbid disorders often improve alongside
PTSD symptoms, such as for depression (e. g., Acierno et al., 2017; Foa
et al., 2013) and associated problems including general anxiety (e.g., Foa
et al., 2005), trauma-related guilt (e.g., McLean et al., 2019), state anger
(e.g., Ford et al., 2018), and dissociation (e.g., Harned et al., 2012). For other
comorbid disorders, trauma-focused PTSD treatment has been found efficacious
when delivered concurrently or integrated with treatment targeting the comorbid
condition. For example, a treatment that integrates prolonged exposure with
CBT for substance use can effectively reduce symptoms of both PTSD and
substance use (e.g., Back et al., 2019). Similarly, integrating prolonged expos-
ure with dialectical behavior therapy (DBT; Linehan et al., 2006) is efficacious
for individuals with PTSD and comorbid borderline personality disorder (e.g.,
Harned et al., 2014).

Demographics
Older age has been linked to lower effect sizes for PTSD treatment in general
(Dewar et al., 2020), and for exposure therapies (McLean et al., 2022) but not
CPT (Asmundson et al., 2019). Additional research is needed to clarify the
impact of age on treatment response, and the interaction of age and treatment
type (e.g., exposure-based vs. cognitive) on outcomes. In terms of gender, the
scope of the literature is limited to binary categories of men and women. Results
from meta-analyses indicate that women benefit more from trauma-focused
treatment than men (Sloan et al., 2011; Wade et al., 2016; Watts et al., 2013).
Specifically, it appears that women benefit more than men from CPT
(Asmundson et al., 2019; Khan et al., 2020), but no gender effects have been
observed in exposure-based treatments (McLean et al., 2022). In clinical trials of
trauma-focused treatments, racial and ethnic disparities in treatment response are
generally not observed (Galovski et al., 2016; Held et al., 2021; McLean et al.,
2022; Rutt et al., 2018), though one study found that African Americans
benefited more from prolonged exposure compared to other ethnicities
(Jeffreys et al., 2014). In contrast, veterans who identify as racial or ethnic
minorities tend to have worse clinical outcomes following routine outpatient
PTSD care through the Veterans Affairs health care system (Maguen et al.,
2014; Sripada et al., 2017). Because race and ethnicity are often conflated and
the scope has been largely limited to examining differences among White,
African American, and Latinx trauma survivors, our understanding of racial
and ethnic difference in PTSD outcomes remains limited.
92 Carmen P. McLean and Eve A. Rosenfeld

Box 6.2 Trauma Type

Different categories of traumatic events, or “trauma types” (e.g., combat, accidents,

interpersonal trauma), have been linked to distinct clinical PTSD symptom profiles (e.g.,
Birkeland et al., 2021; Kelley et al., 2009; Smith et al., 2016), which may potentially
impact differential response to various treatment approaches. Combat trauma and
interpersonal traumas (e.g., sexual assault, domestic violence, armed robbery) appear
to most reliably predict poorer response to trauma-focused treatment (e.g., Bradley
et al., 2005; Karatzias et al., 2019; Straud et al., 2019). However, results are inconsistent
(e.g., Khan et al., 2020; Tiet et al., 2015). It is difficult to disentangle trauma type from
chronicity of trauma exposure, particularly given that combat and interpersonal traumas
are more likely to involve repeated exposure to traumatic stressors compared to, for
example, a natural disaster or accident. Importantly, individuals with more complex
trauma histories may benefit less from group therapy formats (Sloan et al., 2011), so it
may be helpful to prioritize individual therapy for these persons. Although it is unclear to
what extent trauma type versus trauma chronicity contribute to differential outcomes,
both impact clinicians’ perceptions of appropriate treatment approaches. Specifically,
providers perceive greater treatment barriers (e.g., concerns about worsening of
symptoms and dropout) and attenuated suitability of imaginal exposure for patients
with multiple childhood traumas (van Minnen et al., 2010). This may inadvertently limit
access to evidence-based treatment for certain subgroups of trauma survivors.

Medication
Serotonin reuptake inhibitors (SRIs) such as paroxetine, venlafaxine, and fluoxetine
are efficacious pharmacotherapies for PTSD in adults (e.g., Forman-Hoffman et al.,
2018). To date, only a few trials have tested the effects of combining EBPs with SRIs,
and these studies have generally found that adding medication to trauma-focused
psychotherapy does not improve long-term outcomes over medication or psychother-
apy alone (e.g., Popiel et al., 2015; Rauch et al., 2019). Benzodiazepines are not
recommended for PTSD; although they can help with anxiety and sleep in the short-
term, they are not efficacious for treating PTSD and are associated with adverse side
effects over time (Guina & Merrill, 2018). There is also evidence that benzodiazep-
ines interfere with the effects of exposure therapy (e.g., van Minnen et al., 2012),
possibly by promoting avoidance (i.e., functioning as a safety behavior), attenuating
fear activation, and/or interfering with fear extinction (see Guina et al., 2015).

Conclusion
The most well-supported treatments for PTSD are trauma-focused psychotherapies.
All of these treatments include psychoeducation, which can be critical to building
therapeutic rapport, treatment credibility, and expectancy for change during treatment.
 Posttraumatic Stress Disorder 93

Homework is used in most efficacious treatment for PTSD, primarily to extend learning
through additional practice of skills learned in-session and generalization to new
contexts. Exposure and cognitive therapy are the two most often used evidence-based
components of PTSD treatments. These components have been found to be highly
efficacious when used alone (with psychoeducation and often with homework) or when
combined in various ways in different trauma-focused protocols. Most studies have not
found benefit to combining exposure and cognitive therapy techniques relative to
focusing on one approach only, possibly because these approaches share underlying
mechanisms of therapeutic change. For example, a quantitative review of studies
examining exposure therapy with and without additional treatment components (typic-
ally cognitive restructuring) found a small but not clinically meaningful advantage for
treatments with additional components relative to exposure alone on interviewer-
assessed PTSD, and no differences on self-reported PTSD, loss of a PTSD diagnosis,
or rate of treatment dropout (Kehle-Forbes et al., 2013). While some research has begun
to identify potential treatment moderators among demographic (e.g., gender) and
clinical (e.g., trauma type) characteristics, additional research is needed to determine
which treatment approach will be most effective for a given patient. Shared decision-
making is recommended to promote patient-centered care and has been linked with
improved clinical outcomes (Watts et al., 2015).

Useful Resources

• CPT Web https://cpt2.musc.edu

Online training for CPT.
• International Society for Traumatic Stress Studies (ISTSS) https://istss.org/home
ISTSS is a professional association that offers information and resources related to traumatic
stress and its management. The website includes information about PTSD assessment and
treatment in adults and children, as well as provider training, treatment guidelines, and
provider self-care.
• National Center for PTSD (NCPTSD) www.ptsd.va.gov
The NCPTSD is a research and educational center of excellence on PTSD. The website offers
information about PTSD assessment and PTSD treatments, including guidance on shared deci-
sion-making, and the PTSD Consultation Program, which provides clinical didactics and free
expert consultation to any provider working with veterans with PTSD.
• National Child Traumatic Stress Network (NCTSN) www.nctsnet.org
The NCTSN provides clinical services, education, and training to address traumatic stress in
children and their families. It includes information about treatment approaches, psychological
first aid, and trauma-informed care.
• PE Web http://pe.musc.edu
The Medical University of South Carolina is one of several institutions that offers training in
evidence-based treatment for PTSD, including online training for prolonged exposure therapy.
94 Carmen P. McLean and Eve A. Rosenfeld

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 7
Dissociative Disorders
Damla E. Aksen and Steven Jay Lynn

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines

dissociative disorders as “disruption[s] of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion, perception, body rep-
resentation, motor control, and behavior” (American Psychiatric Association,
2022, p. 329). Dissociative experiences range from mild (e.g., absorption in
everyday experiences) to serious and debilitating, as in the case of dissociative
identity disorder (DID). Dissociative disorders encompass depersonalization
(detachment from self, body), derealization (e.g., detachment from surroundings
feelings of unreality), dissociative amnesia (e.g., gaps in autobiographical mem-
ory not accounted for by ordinary forgetting), and DID, formerly called multiple
personality disorder (i.e., presence of distinct personality states, recurrent dis-
sociative amnesia). Other mental health disorders (e.g., posttraumatic stress
disorder, borderline personality disorder [BPD]) consider dissociative symptoms
in formulating a diagnosis. Finally, “other specified dissociative disorder” and
“unspecified dissociative disorder” are characterized by dissociative symptoms
(e.g., dissociative seizures) that do not meet the threshold for any other disorder
and were previously called “dissociative disorder not otherwise specified”
(DDNOS).
Dissociative disorders (DD) are not uncommon, generally falling in the prevalence
range of 1–3% (see Lynn et al., 2019), roughly equivalent to that of schizophrenia or
bipolar disorder. Prevalence rates are higher in clinical populations and vary with
diagnostic methods (e.g., structured versus unstructured interviews), interviewer
reliability, examiner biases, local base-rates, and cultural factors discussed later in
the chapter (see Lilienfeld & Lynn, 2003).
Because clinicians and researchers may be unaware of the prevalence of dissocia-
tive conditions, they may fail to assess and treat symptoms and to systematically
develop and evaluate evidence-based interventions. Concerningly, Langeland et al.
(2020) reviewed four studies regarding the economic burden of DD and tentatively
concluded that DD are “costly to society and that there is a reduction in service
105
106 Damla E. Aksen and Steven Jay Lynn

utilization and associated costs over time with diagnosing of and specialized treat-
ments for DDs” (p. 730).
Apart from societal costs, patients with DD often suffer from severe psychiatric
symptoms; complex emotional, social, and physical health difficulties; and diverse
functional impairments (Myrick, Webermann, Langeland, et al., 2017).
Dissociative experiences are related to ratings of poor quality of life (Polizzi
et al., 2022) and are associated with recurrent hospitalizations, suicide, and high
rates of disability (Langeland et al., 2020). Clearly, effective treatments must be
a high priority.

Etiology and Theoretical Underpinnings of Treatment

To underscore this point, the evaluation of treatments for DD has received sparse
attention compared with other DSM-5-TR disorders. Evidence-based treatments
arguably lag far behind the treatment of most other DSM conditions. One reason is
that the theoretical underpinnings of the treatment of DD are highly controversial.
Some experts have asserted that DD are byproducts of trauma and advocated for
a posttraumatic model (PTM) of dissociation (Dalenberg et al., 2012; Gleaves, 1996).
According to the PTM, processing of past traumatic events should be accorded the
highest priority.
In contrast, proponents of the sociocognitive model (SCM; Lilienfeld et al., 1999;
Lynn et al., 2014; Spanos, 1994) have claimed that while DD may be associated with
severe psychopathology, their genesis often resides in cognitive, social, and cultural
influences (e.g., media, suggestibility, fantasy, symptom overreporting, suggestive
psychotherapies). This model is compatible with cognitive-behavioral interventions
(CBT) and with research from a transdiagnostic/transtheoretical perspective that
considers multiple determinants of dissociation as treatment targets. Research sup-
ports a role for an array of such determinants, including sleep disturbances, cognitive-
affective dysregulation and avoidance, alexithymia, and meta-cognitive processes
(Aksen et al., 2021; Lynn et al., 2019; Serrano-Sevillano et al., 2017; Van der Kloet
et al., 2012).
PTM advocates have maintained that skepticism regarding DD and a lack of
clinician training might account for why DD are not routinely assessed and treated
(Brand et al., 2014, 2016; Leonard et al., 2015; Ş ar & Ross, 2006). However, SCM
proponents have contended that iatrogenic influences (e.g., suggestive methods,
hypnosis) in psychotherapy, and/or patients’ attribution of puzzling symptoms to
a fragmented self, may produce false positive diagnoses (Lynn et al., 2014). We
will consider diagnostic issues in greater depth before we conclude. Nevertheless,
regardless of one’s theoretical perspective, we recommend that clinicians routinely
screen for and carefully evaluate dissociative symptoms. Furthermore, (a) reliable
diagnoses can be achieved in psychotherapy studies using structured interviews,
 Dissociative Disorders 107

regardless of the origin of the symptoms (Leonard et al., 2015), and (b) participants
can be reliably “categorized” and diagnosed in treatment studies.

Brief Overview of Treatments

Research on the treatment of dissociation is deficient in rigorous controlled studies,
although abundant case studies exist (but will not be the focus of our review; see
Maxwell et al., 2018). This state of affairs is arguably attributable largely to the
controversial nature of dissociative conditions spurred, in part, by (a) dramatized
depictions of DD in the media (e.g., movies such as The Three Faces of Eve, Sybil,
Split) and (b) by early and influential depictions of the treatment of DD based on the
PTM. Such portrayals are exemplified in Putnam’s 1989 influential work that pre-
sented suggestive interventions and memory recovery techniques, which some clin-
icians rejected based on concerns about false memories and iatrogenic DID. Such
interventions veered sharply from behavioral, cognitive, and cognitive-behavioral
methods, which came into vogue among psychotherapists and researchers who
practiced and researched evidence-based psychotherapies. The negative reputation
of suggestive interventions likely persists among some contemporary clinicians and
researchers who do not identify DID treatment with well-researched empirically
grounded methods.
Additionally, treatment research has likely been deterred by the intensive, costly,
and long-term nature of DID treatment necessitated by the combination of serious
dissociative conditions alongside comorbid psychopathology. Accordingly, we specu-
late that many researchers have been dissuaded from conducting treatment studies and
pursuing grant funding. Still, researchers have developed and begun to evaluate
promising treatments for dissociative conditions that span a diversity of approaches.
In this chapter, we will review treatments for dissociation and spotlight DID, given
that most concerted research efforts have centered on DID. Nevertheless, we will
allude to other dissociative conditions, such as depersonalization/derealization and
dissociative seizures (e.g., “psychogenic nonepileptic” or “functional” seizures), and
provide recommendations for future research. Given the limited research on DD, we
will depart from other chapters and focus on emerging and promising treatments
rather than on credible components of science-based treatments.

Emerging and Promising Treatments

Phase-Oriented Treatment
We would be remiss in not discussing a commonly used phase-oriented approach to
treating DID and DDNOS, even though it is not yet grounded in systematic controlled
research. This intervention is recommended in guidelines promulgated by the
108 Damla E. Aksen and Steven Jay Lynn

International Society for the Study of Trauma and Dissociation (ISSTD). Although
the phases are presented in a sequential order, they are usually implemented recur-
sively, whereby each phase is evaluated and implemented based on the patient’s
unique needs (Courtois, 1999).
Phase 1 focuses on establishing the therapist alliance (Cronin et al., 2014) and
symptom control. The goal is to build skills necessary to achieve symptom stabiliza-
tion (e.g., reduce self-harm, suicide attempts) and emotion regulation (Nester et al.,
2022; Ş ar et al., 2007). Symptom control can be facilitated by targeting emotional
dysregulation via providing structure, behavioral change, emotion regulation strat-
egies (e.g., grounding, breathing techniques), and medications, as well as devising
safety management strategies (Nester et al., 2022).
Phase 2 focuses on confronting, integrating, and working through memories. This
phase aims to recall, fully experience, process, and incorporate memories of past
events to develop control over them and transform traumatic memories to narrative
memories (Subramanyam et al., 2020). We suggest that clinicians exert due caution in
avoiding aggressive and suggestive memory recovery techniques (e.g., hypnosis,
reifying/mapping alters) throughout treatment.
Finally, phase 3 focuses on integration and rehabilitation with the goal of
stabilizing identity (Pollock et al., 2017) and enhancing mindfulness skills
(Sharma et al., 2016). The guidelines encourage other modalities such as CBT,
schema therapy, family or expressive therapy, and dialectical behavior therapy
(DBT) (Lilienfeld et al., 2013), although group therapy is not recommended as
the primary treatment modality because traditional process-oriented groups tend
to encourage discussion of traumatic experiences and identities that may exacer-
bate dissociation symptoms.
In Bækkelund et al.’s (2022) study, based on these guidelines, individuals diag-
nosed with complex DD did not report immediate improvement after group and
individual therapy. However, they did report significant reductions in symptoms
during the 6-month follow-up.
The ISSTD guidelines certainly merit study. However, as of this writing, it is not
known (a) which intervention in any phase is necessary or sufficient, (b) which
intervention takes precedence over others, and (c) how one or all components fare
when compared with any other (non-phase) treatment.

Treatment of Patients with the Dissociative Disorders Network Program

The prospective longitudinal Treatment of Patients with Dissociative Disorders (TOP
DD) study is the most comprehensive outcome study to date. In this web-based
psychosocial intervention based on 111 international patients, Myrick, Webermann,
Langeland, et al. (2017) reported that individuals diagnosed with DID benefit from
specialized treatment. The research evaluated whether participants evidenced reduced
 Dissociative Disorders 109

symptoms over two years following the utilization of highly diverse interventions
across therapists including educational videos, written and behavioral exercises,
prolonged exposure, eye movement desensitization and reprocessing, grief manage-
ment, CBT, and behavior chain analysis of dissociative episodes. Therapists were
trained to treat DD, and educational materials were developed based on the ISSTD
guidelines (Brand et al., 2012). During the program, participants reported only small
improvements in dissociation; however, at the two-year mark, patients with high
levels of dissociation initially experienced the greatest improvements in emotion
regulation, PTSD, and dissociation. However, regression to the mean is a plausible
explanation for these findings, as a no-treatment control or other comparison condi-
tion (e.g., placebo) was not evaluated.

Cognitive-Behavioral Therapy
Emerging evidence supports CBT in treating dissociation symptoms (Goldstein
et al., 2020; Hoeboer et al., 2020). The use of CBT is based on the rationale that it
can be utilized to reduce avoidance behaviors, linked with persistent posttraumatic
stress, via challenging (inaccurate) meta-cognitive beliefs regarding the existence of
separate indwelling “identities” (see Lynn et al., 2022). These dysfunctional beliefs
promote cognitive-affect-behavioral avoidance of negative emotions and negative
reinforcement of symptoms of depersonalization and derealization that represent
maladaptive safety behaviors present in DD (Chiu et al., 2017; Ş ar et al., 2017).
Derealization and depersonalization, in turn, can be treated with CBT using psy-
choeducation, diary entries to highlight symptom variability, grounding in present-
moment experience, symptom avoidance-reduction, reducing safety behaviors and
self-focused attention, and challenging catastrophic and motivation-degrading
assumptions (Hunter et al., 2003; Hunter et al., 2005; Hunter, 2013). However,
these potential symptom mediators and moderators have not been systematically
isolated or evaluated to date in conjunction with treatment. Van Minnen and Tibben
(2001) relied on CBT principles in a case study of a woman with PTSD and DID
diagnoses. The intervention involved eight days of trauma-focused treatment,
psychoeducation, and participation in physical activities. After two weeks, the
participant no longer met the full criteria for PTSD or DID and maintained gains
at three and six months. Research with larger samples and appropriate comparison
conditions is warranted.
Goldstein et al. (2020) evaluated dissociative seizures in a multicenter randomized
controlled trial in England, Scotland, and Wales based on 313 patients who received
CBT plus standardized medical care or medical care alone. Although no differences
were reported for primary outcome measures, secondary measures (e.g., better quality
of life, less overall psychological distress, seizures rated as less bothersome) provided
evidence for predicted differences favoring CBT.
110 Damla E. Aksen and Steven Jay Lynn

The Unified Protocol

Lynn et al. (2019, 2022) have called for research investigating transtheoretical and
transdiagnostic variables, noted earlier, in and apart from psychotherapy. The relevance
of a transdiagnostic and transtheoretical approach is exemplified in the Unified Protocol
(UP) for the Treatment of Emotional Disorders (Barlow et al., 2017), with demonstrated
effectiveness in treating BPD, mood, anxiety, and somatoform disorders. The UP
enhances emotion regulation by providing psychoeducation, cognitive reappraisal
strategies, emotional and interoceptive awareness training, modifying metacognitions,
exposure to stress/trauma-related triggers, and affect tolerance interventions.
Mohajerin et al. (2020) used the UP to treat five participants diagnosed with DID in
individual 60–90-minute sessions for six months. At treatment termination, none of
the participants met full criteria for DID diagnosis, and results were maintained at six-
month follow-up. Interventions such as the UP, which target variables theoretically
germane to DID, hold promise in treating severe dissociative conditions. Efforts to
promote sleep hygiene would be a valuable addition to the UP and other DID
interventions, given that sleep disturbances (e.g., narcolepsy, sleep paralysis, night-
mares), inadequate sleep, and daytime napping, for example, increase dissociative
symptoms (Arora et al., 2020), whereas improvements in sleep hygiene and sleep
quality decrease dissociative symptoms (Van Heugten et al., 2015).

Dialectical Behavioral Therapy

Comorbidity of BPD and DID, in the range of 31–83% (Foote & Van Orden, 2016;
Korzekwa et al., 2009), may be a function of overlap in transdiagnostic symptoms
such as emotion dysregulation, fluctuations in identity, and poor affect tolerance
(Brand & Lanius, 2014). Foote and Van Orden (2016) adapted DBT, commonly
used to treat BPD, to treat DID in an 18-month case study of a single participant that
included weekly individual DBT, medication management, and participation in
a weekly DBT group.
The researchers relied on three principles (Foote & Van Orden, 2016). The first
involved stabilizing symptoms of behavioral dysregulation or dissociative behaviors
that engender self-harm and interfere with treatment. The second principle utilized
behavioral and solution analysis to target “identities” that are adjudged to harm or
threaten the patient’s life or interfere with treatment. The third principle was to not
consider “switching” between “identities” as maladaptive unless it interferes with
treatment or proves harmful. At six-year follow-up, no notable self-harm behaviors or
suicide attempts were reported, and the patient was able to establish a “life-worth-
living,” defined as a life that includes love, meaning, and compassion for imperfec-
tions (Linehan, 2014) Clearly, more research is required to establish DBT as
a worthwhile treatment for DD.
 Dissociative Disorders 111

Schema Therapy
Unlike the ISSTD guidelines, which incorporate the idea of dissociated “identities,”
schema therapy normalizes and reframes these “identities” by labeling them as modes
that are present in all humans to varying degrees (Young et al., 2003). Huntjens et al.
(2019) educated 10 participants with DID on the functions of the modes as well as
allied behaviors and states linked with these modes. Treatment consisted of 2 individ-
ual weekly sessions, followed by 40 individual weekly sessions. This study is ongoing
and findings are not yet available; however, the laudable aim of the research is to
establish a standardized, evidence-based treatment for DID.

Approaches for Youth

Research on science-based treatments for children and adolescents with DD is lacking
(Nilsson et al., 2019). Assessment of dissociation in children is not done consistently,
and dissociative symptoms may be mistaken for other psychopathology (e.g., schizo-
phrenia, bipolar disorder, ADHD; Diseth & Christie, 2005). Accordingly, treatment
of dissociation may be overlooked or require more time than is optimal due to
misdiagnosis.
Early detection of dissociative symptoms and intervention are important in achiev-
ing a favorable response. Macfie et al. (2001) argue that maltreatment is a risk factor in
developing dissociation, primarily during preschool. Accordingly, effective treatment
should prioritize ending maltreatment and processing traumatic experiences (Macfie
et al., 2001). Emotion dysregulation is also associated with severity of dissociation
symptoms in preschool children (Hébert et al., 2020). Combining individual psycho-
therapy, pharmacotherapy, and family therapy is thought to be necessary to alleviate
dissociation in children (Diseth & Christie, 2005). Diseth and Christie (2005) recom-
mend that therapists create a strong alliance and demonstrate empathy and continuity
toward the child’s experiences with possible imaginary friends or self-states. Creating
science-based therapies is imperative to fill a glaring gap in meeting the needs of
children with dissociative conditions.

Other Variables Influencing Treatment

Assessment and Diagnosis
Some experts have claimed that DD are overdiagnosed and have gone so far as to
argue that they are a “fad” (Paris, 2012). In contrast, other experts have, with equal
ardor, contended that DD are underdiagnosed or misdiagnosed (Ş ar & Ross, 2006).
Unfortunately, few clinicians report adequate training in diagnosing and treating DD,
and some clinicians question the validity of DD (Brand et al., 2014, 2016; Leonard
et al., 2005). On average, misdiagnosed DID patients spend 5 to 12.4 years receiving
112 Damla E. Aksen and Steven Jay Lynn

Box 7.1 Recommendations for Research on Dissociative Conditions

We proffer six recommendations for research regarding dissociative conditions.

1. We recommend clinical trials include waitlist, placebo, and alternate treatment

comparison conditions. We further recommend (a) assessment by trained experi-
menters and exploration of alternative explanations including regression to the
mean, demand characteristics, and nonspecific factors (see Lilienfeld et al., 2014)
and (b) the development of standardized/manualized treatment protocols, which
can be valuable resources, yet not adhered to slavishly or mindlessly.
2. It can be particularly challenging to not reify “separate selves” while engaging with
patients who steadfastly believe in their existence. When objective measures are
employed, researchers have found no support for the actual separation of identities
within a single person (see Lynn et al., 2022). DID appears to be a disorder of belief
in which a person is convinced in the reality of separate indwelling selves. We
recommend that therapists skillfully negotiate these beliefs while working with the
patient to develop a narrative of a single integrated “self.” Research on the UP
(Mohajerin et al., 2020) and schema-based therapy (Huntjens et al., 2019) provide
useful suggestions for how to accomplish this.
3. We recommend that therapists avoid the use of hypnosis or other suggestive
techniques to recover memories, as such procedures risk ratifying the patient’s
belief in a fractured self. Hypnosis is contraindicated because (a) it is based on the
mistaken idea that memory can be stored forever and later accessed in pristine form,
and (b) hypnosis poses risks of false memory creation (Lynn et al., 2020). Fetkewicz
et al. (2000) surveyed 20 individuals diagnosed with DID who reported suicidal
ideation and a history of suicide attempts. Unfortunately, after memory recovery
treatment, 60% of the patients reported suicide attempts, a number higher post-
treatment than pretreatment. The researchers concluded that memory recovery
treatment could be hazardous and detrimental, and we concur.
4. We recommend that researchers develop treatments (e.g., UP, DBT schema-based
interventions) that target transdiagnostic variables and assess mechanisms (e.g.,
emotion regulation, metacognition, sleep disturbances) in studies with follow-ups
at three months, preferably extending to a year or more.
5. We recommend that research be conducted on pharmacological interventions and
whether they can be used effectively with different treatments versus on a stand-
alone basis.
6. We recommend that researchers evaluate not only positive outcomes but also
negative or harmful effects of psychotherapies among individuals with diverse
socioeconomic backgrounds.
 Dissociative Disorders 113

mental health treatment before being accurately diagnosed with DID (Spiegel et al.,
2011). Assessing, isolating, and targeting dissociative symptoms is imperative, as
dissociative symptoms persist and worsen absent effective assessment and treatment
(Brand et al., 2014).

Comorbidity
Dissociative symptoms have received sparse attention and pose problems for psycho-
therapy researchers due to high rates of comorbidity, with many conditions including
BPD, psychotic spectrum disorders, depression, anxiety, avoidant personality, sub-
stance abuse, and eating disorders. These disorders might overshadow or mask
diagnosis of dissociative symptoms, eventuate in misdiagnosis and false-negatives
(Ş ar & Ross, 2006), and relegate treatment and research to a low priority (Ellickson-
Larew et al., 2020; Foote & Van Orden, 2016; Korzekwa et al., 2009). Jepsen et al.
(2014) concluded that patients need dissociation-specific treatment to achieve posi-
tive results, although this assertion awaits systematic evaluation. Belli (2014) found
that, among patients with OCD, dissociation correlated with severity of OCD symp-
toms, and patients who did not improve after treatment experienced high levels of
dissociative symptoms. However, Hoeboer et al. (2020), in their meta-analytic review
of 1,714 patients, found no evidence that dissociation mediated effectiveness of
psychotherapy for PTSD.

Demographics
Ghosh et al. (2021) identified racial, socioeconomic, ethnic, and age group back-
grounds as impacting DD, with women more affected than men. DSM-5-TR criteria
do not adequately address unusual yet culturally relevant dissociative experiences
such as possession. Dorahy et al. (2014) posit that cultural identity with a deity and
other sociocultural factors impact and complicate research and treatment of DD. For
example, religious practices impact mental disorders, including the expression of
dissociation, possession experiences, and out-of-body phenomena (Dorahy et al.,
2014). Anglin et al.’s (2015) research, which accounted for cultural variation
among ethnic minority groups, revealed that dissociation mediates the association
between traumatic life events and attenuated positive psychotic symptoms, particu-
larly among Black participants. Similarly, Brand et al. (2006) reported that a high
prevalence of DD was associated with unique cultural manifestations. In some
cultures, recurrent recall gaps may be considered ordinary forgetting, and experiences
of two or more distinct personality states may be regarded as possession. Brand et al.
(2016) studied 48 institutions in 16 countries and reported that possession experiences
and DD occurred at different rates, possibly depending on whether clinicians endorse
common myths about dissociation (e.g., “DID is a fad”). For example, prevalence
114 Damla E. Aksen and Steven Jay Lynn

Box 7.2 Access to Treatment

Even when patients are diagnosed correctly, they might encounter barriers to accessing
treatment, such as high cost. Myrick, Webermann, Langeland, et al. (2017) compared
the changes in inpatient and outpatient costs for individuals diagnosed with DID. The
researchers found that (a) estimated costs are lower for patients who receive treatment,
(b) treatments for dissociation typically take years to complete, and (c) treatments are
often costly. In contrast, patients with DD in Norway can seek free care at a three-month
inpatient treatment program; similar programs are nonexistent in the United States
(Jepsen et al., 2014).

rates for DID were two to three times higher in the United States compared to Canada
and European countries such as the Netherlands and Germany.

Medication
Psychopharmacology interventions are not very effective and therefore have been
utilized as a second-line treatment for dissociation, particularly when psychotherapy
alone does not produce relief (Bridley et al., 2022). Commonly prescribed medica-
tions include serotonin reuptake inhibitors and monoamine oxidase and tricyclic
antidepressant inhibitors (Kolla et al., 2016). Monoamine oxidase inhibitors are
somewhat effective and are primarily utilized to treat DD with co-occurring major
depressive disorder symptoms (Kolla et al., 2016). Sutar and Sahu (2019) systematic-
ally reviewed 214 participants with DD who received psychopharmacological treat-
ment and concluded that paroxetine and naloxone are the only agents that improve
dissociation (e.g., depersonalization) symptoms in individuals with comorbid PTSD
and BPD. However, the role of placebo effects has not been adequately evaluated in
the treatment of dissociation. Additionally, Gentile et al. (2013) caution practitioners
against using benzodiazepines in patients with DD to prevent exacerbating symptoms
of dissociation. To our knowledge, no research exists regarding the efficacy of
combining medication and psychotherapy for dissociation.

Conclusion
Individuals who suffer from dissociative conditions are in great need of science-
based treatments that are currently minimally studied or nonexistent.
Commendably, researchers are beginning to accord the treatment of dissociation
the attention that it deserves. Still, science-based treatments are in their infancy: No
intervention has been investigated systematically, and promising initial findings
must be replicated in order to be regarded as robust and convincing. For example, no
 Dissociative Disorders 115

extant treatment meets the Tolin et al. (2015) criteria or David and Montgomery’s
(2011) criteria for well-supported and evidence-based psychosocial interventions,
which include rigorous evaluation of hypothesized change mechanisms.
Unfortunately, RCTs are virtually absent, controlled case studies are scant, and
mechanistic studies are nonexistent. We hope that our chapter spurs researchers to
undertake the necessary research to meet the needs of people with DD, and that they
do so in a timely manner.

Useful Resources

• Bridley, A., Daffin, L. W., & Washington State University. (2022). Fundamentals of
psychological disorders (formerly abnormal psychology) 3rd edition (5-TR) (3rd ed.).
Press Books.
• Chien, W. T., & Fung, H. W. (2022). The challenges in diagnosis and treatment of dissociative
disorders. Alpha Psychiatry, 23(2), 45–46. https://doi.org/10.5152/alphapsychiatry.2022.0001.
• Diseth, T. H., & Christie, H. J. (2005). Trauma-related dissociative (conversion) disorders in
children and adolescents – An overview of assessment tools and treatment principles. Nordic
Journal of Psychiatry, 59(4), 278–292.
• Kring, A. M., & Johnson, S. M. (2018). Abnormal psychology: The science and treatment of
psychological disorders (14th ed.). John Wiley & Sons, Inc.
• Maxwell, R., Merckelbach, H., Lilienfeld, S. O., & Lynn, S. J. (2018). The treatment of
dissociation: An evaluation of effectiveness and potential mechanisms In D. David,
S. J. Lynn, & G. H. Montgomery (Eds.), Evidence-based psychotherapy: The state of the
science and practice (pp. 329–361). Wiley Blackwell.
• Mohajerin, Lynn, S. J., Bakhtiyari, M., & Dolatshah, B. (2020). Evaluating the Unified
Protocol in the treatment of dissociative identify disorder. Cognitive and Behavioral
Practice, 27(3), 270–289.
• Pieper, S., Out, D., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2011).
Behavioral and molecular genetics of dissociation: The role of the serotonin transporter
gene promoter polymorphism (5-HTTLPR). Journal of Traumatic Stress, 24(4), 373–380.
• Ş ar, V., Dorahy, M., & Krüger, C. (2017). Revisiting the etiological aspects of dissociative
identity disorder: A biopsychosocial perspective. Psychology Research and Behavior
Management, Volume 10(10), 137–146. https://doi.org/10.2147/prbm.s113743
• Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s
guide. The Guilford Press.

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 8
Pain
Laura Nelson Darling, Kristine Lee, and John Otis

Pain is defined as an unpleasant sensory and emotional experience associated

with actual or potential tissue damage or described in terms of such damage
(Classification of Chronic Pain; Merskey & Bogduk, 1994). The experience of
pain is typically an adaptive reaction to injury and serves to limit movement and
allow healing to occur. Often referred to as “acute” pain, this type of pain is
associated with injuries such as a burn, sprained ankle, or broken bone, and
resolves on its own following conservative treatment. Chronic pain differs due to
persistence, sometimes lasting years, without a continued underlying physical
cause. When pain persists for more than three months in duration it is con-
sidered “chronic” (Merskey & Bogduk, 1994).
Chronic pain is one of the most common reasons people seek health care in
the United States. In fact, a survey by the Centers for Disease Control and
Prevention indicated that about 21% of adults reported having “pain most days
or every day” for the past six months (Rikard et al., 2023). Chronic pain can
have a devastating impact on all aspects of a person’s life; thus, there are high
rates of comorbidity with emotional disorders (Kroenke et al., 2013; Staerkle
et al., 2004).
Given the high prevalence, costs, and distress associated with the experience
of chronic pain, efforts to develop evidence-based psychological approaches to
help patients learn more effective pain coping strategies have expanded in the
last decade. This chapter will provide a review of the theoretical models that
have contributed to our understanding of psychological approaches to chronic
pain management. The chapter describes two evidence-based treatments for
pain – cognitive-behavioral therapy (CBT) and Acceptance and Commitment
Therapy (ACT) – and presents data supporting their use. The chapter then turns
to describing individual components in each treatment approach that have been
found to be essential. Since pain can occur across the lifespan, the chapter also
addresses pain in children.

122
 Pain 123

Box 8.1 Somatic Symptom Disorder

Individuals with chronic pain may present in ways that are consistent with the
diagnostic criteria associated with Somatic Symptom and Related Disorders, with
predominant pain. For example, consider the case of a person who experiences pain
secondary to an injury that requires rest and rehabilitation or medical intervention for
healing to occur. Once the injury has been medically addressed, the person may still
experience painful sensations. In these situations, the person may intensely focus on
the sensations of pain, and may even be hypervigilant to noticing sensations that would
have previously been ignored. These sensations may trigger worry that pain is indication
of underlying pathology or that some type of damage is being done. As a result, the
person may seek medical interventions or pharmaceuticals to reduce pain, alter their
gait, or limit their involvement in work or other activities that they believe have the
potential to increase pain. In this example, given the excessive thoughts, feelings, and
behaviors related to pain, and the disruption to daily life, clinicians might consider
a diagnosis of Somatic Symptom Disorder, with predominant pain from the Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition-Text Revision (DSM-5-TR;
American Psychological Association, 2022).

Etiology and Theoretical Underpinnings of Treatment

The onset of chronic pain may be associated with a number of different health issues,
including medical illness or injury, changes in the body associated with aging, or
neurological conditions. Chronic pain can be experienced in many different ways:
from neuropathic pain that may be described as “burning” or “shooting” sensations; to
somatic, meaning activation of pain receptors on the surface of the body or musculo-
skeletal tissues; or visceral, referring to the activation of pain receptors located in
internal organ systems. Individuals who experience chronic pain may seek medical
consultation with the goal of determining the underlying cause of the pain sensation
and advice on treatment. While early theoretical conceptualizations of pain centered
exclusively on biological or pathophysiological processes, we now understand that
pain is a complex experience that is influenced not only by the presence of underlying
pathology, but also by an individual’s thoughts, emotions, and behaviors. In the past,
psychology was only involved in patient care when medical interventions failed to
obtain a desired patient outcome; however, given our evolving understanding of pain,
providers are increasingly involving psychology early in the treatment process.
Vlaeyen and Linton (2000) proposed a Cognitive-Behavioral Fear–Avoidance
Model of chronic pain to explain the role of fear and avoidance in the transition
from acute to chronic pain. In this model, a person might interpret the experience of
pain as overly threatening (a process called “catastrophizing”), leading them to fear
the experience of pain and avoid activities that they believe might potentially cause
124 Laura Nelson Darling, Kristine Lee, and John Otis

pain. “Guarding” behaviors may follow, such as tensing or bracing muscles to prepare
for movement, using caution while walking, or otherwise altering posture in prepar-
ation for pain. Heightened alert to the mistaken belief that any pain is a sign of damage
or yet-to-be-identified pathology may cause the individual to become hypervigilant to
sensations, and may cause the amplification of low-intensity painful sensations. As
the fear and avoidance of physical activity grows, the world in which the individual
functions becomes more restricted. Avoidance of physical activity also limits oppor-
tunities to test and correct pain expectations. Decreased engagement in pleasurable
and reinforcing activities may lead to depression. On the other hand, in the absence of
serious somatic pathology, an individual who interprets pain as nonthreatening, and
who engages in adaptive problem-solving instead of catastrophizing, is more likely to
have a speedier recovery. Since the introduction of this model, studies have shown
that fear and avoidance of movement is an even better predictor of disability than
underlying biomedical pathology (Crombez et al., 1999). This model has served as the
basis of research and clinical practice for decades and has helped in our formulation of
treatments designed to help patients adaptively cope with the experience of chronic
pain. As our understanding of the factors that may contribute to the etiology and
maintenance of pain disorders has advanced, so has our repertoire of empirically
supported strategies that are available to help patients cope more effectively.

Brief Overview of Treatments

Empirically supported psychological approaches to chronic pain management pri-
marily target improvements in physical, emotional, social, and occupational function-
ing, rather than eliminating the pain itself. A number of studies have demonstrated
that both CBT and ACT may result in improvements in various pain-relevant out-
comes for patients with a variety of pain disorders; however, when evaluating the
evidence supporting the use of a treatment it is important to consider the quality of the
evidence (i.e., presence of high-quality meta-analytic reviews) and contextual factors
(i.e., treatment effects are observed across several patient populations) when deter-
mining an overall treatment recommendation (Tolin et al., 2015).
CBT interventions for chronic pain utilize psychological principles to help intro-
duce flexibility in ways of thinking, modify negative thoughts and behaviors that
serve to maintain and exacerbate the experience of pain, and teach patients ways of
safely reintroducing enjoyable activities into their lives. A substantial literature
documents the efficacy of CBT for a variety of chronic pain conditions, including
osteoarthritis, chronic back and neck pain (Linton & Ryberg, 2001), diabetic neuro-
pathic pain (Otis et al., 2013), and tension headache (Holroyd et al., 2001). The
evidence-base of CBT for pain management also includes a number of meta-analytic
studies (Morley et al., 1999; Williams et al., 2020; Parrish et al., 2021). In a meta-
analysis of 22 randomized controlled trials of psychological treatments for chronic
 Pain 125

low-back pain, cognitive-behavioral and self-regulatory treatments specifically were

found to be efficacious (Hoffman et al., 2007). Further, the positive effects of CBT
were noted in a recent meta-analysis examining pain in children and adolescents
(Palermo et al., 2010).
When utilized within the context of managing chronic pain, ACT aims to limit the
control that pain has on a person’s life by teaching them to accept and live with pain,
and to set goals that are consistent with their values (Roditi & Robinson, 2011).
Although there is support for the use of ACT as a comparable alternative to CBT, the
literature supporting ACT as an effective treatment for pain disorders is mixed.
A meta-analysis examining ACT in patients with chronic pain demonstrated favorable
outcomes, revealing small to medium effect sizes across pain intensity, mood and
affect, physical well-being, and quality of life (Veehof et al., 2011), and a follow-up
meta-analysis found small effects at posttreatment across domains of pain intensity,
depression, and disability (Veehof et al., 2016). However, the Cochrane review of
chronic non-cancer pain judged ACT trials to be of very low quality and determined
that its benefits are uncertain (Williams et al., 2020). Thus, while the use of ACT for
pain is promising, additional high-quality, disorder-specific randomized controlled
trials are needed.

Credible Components of Treatments

Both CBT and ACT are composed of a number of skills that are designed to help
a patient cope more effectively with their chronic pain. What follows is a description
of some of the “essential elements” of treatment for both approaches.

Behavioral Goals
Patients with chronic pain often report that the experience of pain has significantly
interfered with their ability to engage in daily functioning and social activities that
they once found enjoyable. Patients may also avoid activities in an effort to control or
reduce the potential for pain (e.g., not taking a walk for fear that it will cause an
increase in pain); however, this strategy has actually been shown to increase sensitiv-
ity to and chronicity of pain symptoms (Philips, 1987). In order to address these
issues, it’s important for clinicians to collaborate with their patient to create a set of
overall behavioral goals for therapy with the goal of decreasing the patient’s avoid-
ance of activity and reintroducing a healthy and more active lifestyle. Some patients
may choose goals that involve physical functioning, such as walking, playing sports,
or going to the gym; however, goals may also include activities that are far less
physically demanding, such as computer work, reaching out to friends, and socializ-
ing. In situations where a patient can identify an activity that they once found
enjoyable but they are no longer able to perform because of pain or other health
126 Laura Nelson Darling, Kristine Lee, and John Otis

issues (e.g., spinal instability), therapists will need to work with the patient to modify
the goals so that they are realistic and consistent with their interests and abilities.

Exposure
Exposures for individuals with pain disorders may include activities such as engaging
in movements believed to be painful for an individual with chronic back pain, wearing
clothing items associated with pain in an individual with fibromyalgia, or eating
foods that trigger pain symptoms in an individual with irritable bowel syndrome.
Promisingly, research has found exposures to be an effective method for reducing
pain-related fear and disability (for review, see Vlaeyen & Crombez, 2020). Relative
to treatments that implement graded activity, exposure-based treatments have been
shown to be equally effective at reducing pain and disability (e.g., for chronic low-
back pain; Macedo et al., 2010) and possibly even more effective in the short-term
(Lopez-de-Uralde-Villanueva et al., 2016). However, unlike graded activity, expos-
ures have been shown to reduce pain-related anxiety and cognitions, such as fear-
avoidance beliefs (Woods & Asmundson, 2008), pain catastrophizing (Leeuw et al.,
2008), and perceived harmfulness of activities (Leeuw et al., 2008). Thus, exposures
may confer additional therapeutic benefits beyond other behavioral approaches.

Activity Pacing
When engaging in activities, it is important that patients learn to balance being active
with resting in order to accomplish daily activities without overdoing it and experien-
cing increased pain. Activity pacing is a coping strategy that aims to adjust physical
activity to manageable and time-limited increments to reduce pain and fatigue
associated with overexertion. Activity pacing addresses the negative impact of both
underactivity (i.e., avoidance) and overactivity cycling – a maladaptive pattern of
behavior in pain disorders sometimes termed boom–bust cycling (Antcliff et al.,
2018). In activity pacing, the duration and/or intensity of activity can be gradually
increased as individuals learn to manage physiological and psychological symptoms.
Researchers have implemented different methods of activity pacing for pain dis-
orders, including daily schedules alternating activity and rest, and pacing based on
time- or goal-contingencies (the operant approach; Nielson et al., 2013). The latter
approach teaches individuals to initiate rest periods after they reach a predetermined
time-period (e.g., five minutes of activity) or quota (e.g., folding five shirts), rather
than resting only after they experience an increase in pain symptoms. Although
further research is needed to evaluate the relative effectiveness of different activity
pacing approaches, initial studies suggest there may be slight advantages to the
operant approach with certain pain disorders (Racine et al., 2019). Activity pacing
is a key treatment component used by physical therapists when treating patients with
 Pain 127

chronic pain (Beissner et al., 2009), and is a common treatment component in CBT for
pain disorders; however, it is also compatible with ACT when applied through the
lens of acceptance, flexibility, and value-engagement. Specifically, activity pacing
(and behavioral interventions more generally) is consistent with ACT principles when
aimed toward engaging in meaningful activities and setting meaningful goals
(Antcliff et al., 2018).

Cognitive Skills Training

Cognitive skills training is a core component of CBT for pain and aims to intervene in
attentional biases and maladaptive cognitions that exacerbate the pain experience.
Research shows that individuals with pain disorders may exhibit excessively fearful
and catastrophic cognitions regarding anticipated or current pain (Burns et al., 2012;
Sullivan et al., 2001). Catastrophizing is a cognitive distortion defined by excessively
negative predictions or attributions – in other words, “thinking the worst.”
This cognitive style is associated with the magnification of pain sensations and is
considered an important target of pain disorder treatment (Quartana et al., 2009).
Cognitive change (e.g., altering catastrophic pain-related cognitions) is a therapeutic
mechanism specific to CBT. Randomized controlled trials have demonstrated that
CBT interventions produce significant changes in individuals’ cognitive coping and
appraisal skills (Morley, 1999). Accordingly, research has shown that CBT interven-
tions that shift an individual’s pain-related cognitions are linked to significantly
improved outcomes (Burns, Glenn, et al., 2003; Burns, Kubilus, et al., 2003).
Research has shown that reduction in pain catastrophizing following treatment is
significantly associated with improved outcomes, irrespective of the treatment condi-
tion (Burns et al., 2012). This suggests that changes in pain-related cognitions may be
an important mediator of treatment outcome.

Acceptance
Acceptance is a process that involves a willingness to experience pain rather than
escape it. Acceptance methods promote the engagement of goal-oriented action
toward unwanted experiences (e.g., pain, emotions, thoughts). The objective within
ACT is to improve functioning and decrease interference of pain, using acceptance as
a mediator for change (Cederberg et al., 2016). While control-oriented treatments,
such as CBT, generally do not emphasize acceptance as a treatment component,
efforts have been made to identify treatment mediators that could be used to improve
CBT treatment outcomes. Multiple studies suggest that greater acceptance of chronic
pain is associated with better psychological, physical, and social functioning (e.g.,
McCracken & Vowles, 2007; Vowles et al., 2007). Acceptance also appears to be
a key process involved in treatment gains (Vowles et al., 2007), reduces the adverse
128 Laura Nelson Darling, Kristine Lee, and John Otis

impact of pain flares on emotional functioning (Kratz et al., 2007), and is predictive of
future functioning (McCracken & Eccleston, 2005). Research on the effectiveness of
ACT has demonstrated significant medium-to-large effect sizes for measures of pain
acceptance (Hughes et al., 2017). Åkerblom and colleagues (2015) reported findings
that highlight the role of pain-related acceptance as important to the treatment process
even if it is not explicitly targeted during treatment. Based on their mediator analyses,
pain-related acceptance significantly partially mediated changes in outcome measures
during a CBT-based treatment program, even when other potential CBT process
variables were taken into account. Previous research has examined potential process
variables in CBT approaches for chronic pain (i.e., pain beliefs, perceived control
over pain, coping); however, analyses indicated that changes in pain-related accept-
ance, which is not considered a target of traditional CBT, play an important role
(Åkerblom et al., 2015). Thus, incorporating acceptance of pain as an additional
treatment mechanism may enhance CBT-based treatments to improve individuals’
functioning and outcomes.

Relaxation
Relaxation training is often included in interventions for pain disorders. The aim of
relaxation training is to intervene on physiological factors such as increased muscle
tension that may contribute to pain. Strategies include techniques such as diaphrag-
matic breathing, progressive muscle relaxation (PMR), visual imagery, biofeedback,
or a combination thereof. A review of relaxation techniques for acute and chronic pain
found some evidence for reductions in pain outcomes (Dunford & Thompson, 2010).
Although research suggests that relaxation training may not confer as many lasting
benefits compared to CBT (Turner, 1982), practicing relaxation and taking time to
“slow the mind” and notice thoughts may facilitate the practice and development of
cognitive skills (Burns et al., 2015). Further, recent research investigating the mech-
anisms of change in CBT for chronic pain found that change in the use of relaxation
techniques was associated with changes in disability and depression, as was the use of
cognitive techniques (Feldmann et al., 2021). Taken together, these findings suggest
that relaxation strategies may not be adequate for producing lasting benefits on their
own, but may be an impactful component of treatment packages that include other
evidence-based strategies.

Mindfulness
Mindfulness practices have become widely used as self-management techniques for
various long-term conditions, including chronic pain. Based on ancient eastern and
Buddhist philosophy, mindfulness involves attentional control toward the present
moment with acceptance, curiosity, and nonjudgment (Bishop et al., 2004; Hilton
 Pain 129

et al., 2017). For people with chronic pain, inflexible attention and lack of awareness
of the present moment can lead to increased rumination and magnification of pain
(Schütze et al., 2010). Mindfulness practices facilitate refocusing the mind to increase
awareness of external and internal sensations, allowing individuals to self-regulate
attention and reframe experiences. Research has demonstrated that mindfulness
practices appear to be beneficial treatment components to management of chronic
pain and are predictive of patient functioning (Kabat-Zinn et al., 1985; Sephton et al.,
2007). Moreover, research suggests that the use of mindfulness approaches is associ-
ated with greater success in engaging in values-related behavior related to less distress
and disability (McCracken & Yang, 2006). Mindfulness is a core component of ACT.
In the context of chronic pain, awareness of physical sensations, feelings, and
thoughts is needed to give rise to acceptance (Hayes et al., 2006). When attention is
focused on the opportunities of the present rather than ruminating about the past or
catastrophizing about the future, behavior can be directed toward realizing valued
goals instead of pain control (McCracken & Vowles, 2014). While mindfulness has
not been an explicit treatment component of CBT, it has been increasingly incorpor-
ated in recent years through the creation of diverse approaches such as mindfulness-
based cognitive therapy (MBCT; Segal et al., 2018), MBCT for chronic pain (Day,
2017), and mindfulness-based stress reduction therapy (MBSR; Kabat-Zinn, 2003).
Across these interventions, the primary focus is to remain in the present and increase
awareness of emotional and physical suffering (Pardos-Gascon et al., 2021).

Psychological Flexibility
Unifying several of the processes described herein, researchers have proposed that
values-based action, mindfulness, acceptance, and cognitive defusion (a strategy that
involves creating space between oneself and one’s thoughts and feelings) collectively
comprise psychological flexibility (Vowles & McCracken, 2010). Psychological
flexibility has been defined as the capacity to persist or to change behavior, including
conscious and open contact with discomfort and other discouraging experiences,
guided by goals and values (Hayes et al., 1999). Others have described this ability
as “one of the foremost goals of human existence” (Kashdan & Rottenberg, 2010,
p. 866). Psychological flexibility has been proposed as a model for the treatment of
chronic pain (“The Psychological Flexibility Model”; McCracken & Morley, 2014)
and as a mechanism of change in ACT for chronic pain (Scott & McCracken, 2015).
Research suggests that psychological flexibility is both a resilience factor in chronic
pain, buffering the impact of symptoms on functioning and depression (Gentili et al.,
2019), and an important treatment target. Research from McCracken and Vowles
(2007) found that psychological flexibility accounted for significant variance in
measures of adaptive functioning among patients with chronic pain. By contrast,
traditional pain management strategies, such as pacing, relaxation, and positive
130 Laura Nelson Darling, Kristine Lee, and John Otis

self-statements, did not account for significant variance on those same measures.
Similarly, this research team found that treatment-related change in psychological
flexibility was significantly related to improvement in several outcome measures,
including pain, physical disability, psychosocial disability, and medical visits
(McCracken, 2024). Taken together, these findings suggest that psychological flexi-
bility is a key target of treatments for pain disorders and supports the effectiveness of
its component parts: values-guided action, mindfulness, and acceptance.

Approaches for Youth

Psychological treatments for youth with pain disorders generally mirror those for
adult populations. Thus, treatments commonly follow behavioral and cognitive-
behavioral approaches, and may include exposure, acceptance, coping skills training,
relaxation training, and biofeedback. Reflecting the adult literature, psychological
interventions for pain disorders in youth show significant positive effects on key
outcomes (e.g., pain, disability, depression), though the size of the effect and the
outcomes impacted depend on the study, disorder, and treatment approach. Other
research has evaluated the effects of distinct treatment approaches on youth with
chronic pain. A meta-analysis of psychological treatments for children and adoles-
cents with chronic pain (including headaches, abdominal pain, and fibromyalgia)
found that CBT, relaxation therapy, and biofeedback all yielded significant positive
effects on pain reduction; however, results revealed small, nonsignificant effects of
treatment on disability and emotional functioning, which were included as outcomes
in a subset of studies (Palermo et al., 2010). Generally, these findings reflect prior
systematic reviews showing that psychological treatments – primarily brief behav-
ioral and cognitive-behavioral interventions – resulted in significant reductions in
pain symptoms in youth with chronic headaches (e.g., Eccleston et al., 2002).
Promisingly, self-administered, computer-based applications (i.e., CD-ROM, inter-
net) and face-to-face treatments were found to be similarly effective at reducing pain
(Palermo et al., 2010), suggesting room for flexibility in treatment formats.

Other Variables Influencing Treatment

Assessment and Diagnosis
Prior to considering an approach for treatment, it is important to conduct a pain
assessment in order to gather information about the patient’s experience of pain. This
will help the therapist to determine the treatment elements that will likely be of greatest
benefit to the patient. For example, understanding the factors associated with the onset
of the patient’s pain (e.g., motor vehicle accident, assault, degenerative changes) and the
anticipated chronicity of the painful condition will impact the focus of therapy.
 Pain 131

It is also important to learn about strategies the patient has already undertaken to
manage their pain. Assessment includes asking about what seems to make the pain
increase and what tends to reduce it. Assessing for beliefs and expectations, coping
strategies, and other cognitive processes helps to provide a full picture of an individ-
ual’s strengths and vulnerabilities. The patient is the “expert” on their pain, and it is
the therapist’s job to find out what the patient already knows so that treatment can
build upon those existing skills.

Comorbidity
Individuals with chronic pain often experience mental health problems such as
anxiety, depression, posttraumatic stress, or substance use disorders. In chronic
pain samples, depression prevalence rates range from 30–54% (Banks & Kerns,
1996; Elliott et al., 2003). Rates of anxiety are reported to be as high as 45% in
pain populations (Kroenke et al., 2013; Staerkle et al., 2004). Comorbidity with
emotional disorders can complicate the delivery of many aspects of therapy,
including behavioral activities, activity engagement, cognitive training, and
eliciting motivation to participate (Kerns & Haythornthwaite, 1988). Substance
use may also be a way to cope with pain or its comorbidities. Substance use
often interferes with the acquisition of psychotherapeutic skills, thus in cases
where a substance use disorder is present, treatment of the substance use
disorder should take precedence over engagement in psychological approaches
for pain management.

Demographics
Research supports that there are racial and ethnic differences in the ways that people
experience pain, and that race and ethnicity may also lead to differences in pain
treatment preferences. In addition, there are also racial and ethnic disparities in the
ways that pain treatments are provided. For example, studies indicate that people of
color are more likely to have their pain underestimated by providers, are less likely
to receive opioids as part of their pain management regimen, and receive less
aggressive pain treatment than do White patients (Meints et al., 2019). While
many studies exist documenting the benefits of psychological approaches to pain
management for children and adults, fewer studies have involved older adults.
A recent meta-analysis involving 22 studies with 2,208 participants with a mean
age of 71.9 years concluded that psychological therapies have a small but statistic-
ally significant benefit for reducing pain and catastrophizing beliefs and improving
self-efficacy for managing pain in older adults (Niknejad et al., 2018). Overall,
studies support that individuals of all ages can benefit from learning strategies for
managing their pain.
132 Laura Nelson Darling, Kristine Lee, and John Otis

Medication
Pain medications can be helpful in many circumstances, including reducing pain
intensity for individuals with acute pain, facilitating patient participation in rehabili-
tation efforts, and allowing patients with chronic pain to gain greater quality of life.
The use of pain medication is not an exclusion criterion for participation in psycho-
logical treatment for pain. However, there are situations in which the use of pain
medications is not desirable. For example, some patients may experience negative
side effects from pain medication, such as constipation or dizziness. There may also
be situations in which a patient with a history of substance use disorder will feel that
the use of any pain medication may place them at risk for relapse. When working with
a patient who is taking pain medications, therapists can talk openly about the ways
that psychological therapies can provide them with more “tools” in their arsenal for
managing pain, and that therapy can be used as an alternate to medication or in
conjunction with pharmacological approaches to allow prescribed pain medications to
work more effectively (Jamison & Mao, 2015).

Conclusion
Chronic pain is a highly prevalent condition that can have tremendous negative
impacts on multiple domains in life, causing patients and their families significant
distress and causing interference in daily functioning. Fortunately, several psycho-
logical approaches have now been developed that have garnered large evidence bases
over the past few decades. CBT- and ACT-based approaches to treat chronic pain are
comprised of some distinct and some overlapping skills aimed at helping patients gain
greater capability in managing their pain. Importantly, therapists should tailor their
treatments to individual patients with flexibility, rather than being wed to one particu-
lar protocol. Skills such as relaxation and mindfulness, cognitive skills, activity
pacing, acceptance, behavioral activation, and exposure can all be used interchange-
ably depending on the needs of the patient. With a thorough assessment of the
variables maintaining pain, and by considering comorbidities and other demographic
variables that might influence treatment outcome, clinicians can thoughtfully and
sensitively design a treatment plan that will yield the most positive outcomes.

Useful Resources

• Dahl, J., Lundgren, T., & Hayes, S. C. (2006). Living beyond your pain: Using acceptance
and commitment therapy to ease chronic pain. New Harbinger Publications.
• Otis, J. D. (2007). Managing chronic pain: A cognitive-behavioral therapy approach,
therapist guide. Treatments that Work Series. Oxford University Press.
• Thorn, B. (2017). Cognitive therapy for chronic pain, second edition: A step-by-step guide.
The Guilford Press.
 Pain 133

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 9
Eating Disorders
Jamie M. Loor, Jennifer A. Battles, Brooke L. Bennett,
Danae L. Hudson, and Brooke L. Whisenhunt

Eating disorders are characterized by a variety of symptoms, including disruption in

normative eating behaviors, body-image disturbance, and/or maladaptive attempts
to control weight and shape. The Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition, Text Revision (DSM–5-TR; American Psychiatric
Association, 2022) includes four primary eating disorders most common in adults:
anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and other
specified feeding and eating disorder (OSFED). The lifetime prevalence of eating
disorders is high, with approximately 1 in 5 females and 1 in 7 males meeting criteria
for an eating disorder by age 40 (Ward et al., 2019). The most common age for
developing an eating disorder is 21 years old, with 95% of first-time cases occurring
by age 25 (Ward et al., 2019). Although most eating disorders consist of a single
episode, a significant subset of individuals will have recurrent episodes throughout
adulthood (22% of male patients and 29% of female patients; Ward et al., 2019).
Additionally, eating disorders are associated with a high level of impairment and
reduced quality of life (van Hoeken & Hoek, 2020), underscoring the importance of
science-based treatments for eating disorder pathology.
AN is characterized by restriction of caloric intake resulting in significant weight
loss. Intense fear of weight gain is present and interferes with the individual’s ability
to sufficiently increase caloric intake in order to gain weight. Other key features of AN
include an overvaluation of weight and shape, a disturbance in the perception of
weight and shape, and persistent lack of recognition of the ramifications of pursuing
and achieving a low-weight status. Both BN and BED are marked by repeated binge
eating episodes in which an objectively large amount of food is eaten within
a relatively short period of time (i.e., two hours or less), accompanied by a sense of
loss of control over eating. During binge eating episodes, the individual may feel
uncomfortably full, eat rapidly, or eat in the absence of hunger. Eating may occur in
isolation due to embarrassment or guilt, and a feeling of disgust with oneself often
follows the binge episode. The distinguishing factor between BN and BED is that in
BN the individual attempts to “compensate” for the binge eating through behaviors
139
140 Loor, Battles, Bennett, Hudson, and Whisenhunt

such as self-induced vomiting, fasting, excessive exercise, or misusing medications

such as laxatives, diuretics, or diet pills. In contrast, individuals with BED do not
typically engage in compensatory behaviors following a binge episode. Although
overvaluation of weight and shape is required for BN and not BED, research suggests
that individuals with BED who also experience overvaluation of weight and shape
have poorer treatment outcomes and more severe symptoms than do those who do not
overvalue weight and shape (Grilo et al., 2013). The DSM-5-TR also includes an
OSFED category. This category was designed to capture distressing and impairing
eating disturbances that do not fit the other specific diagnostic categories. For
example, OSFED can include individuals at or above a normal weight who otherwise
meet criteria for AN, individuals experiencing subthreshold BN in terms of the
frequency of binge eating and compensatory behaviors, individuals engaging in
purging without binge eating, and individuals who experience night eating.

Etiology and Theoretical Underpinnings of Treatment

The Transdiagnostic Theory of Eating Disorders, first posed by Fairburn and col-
leagues (2003) in the context of Enhanced Cognitive Behavioral Therapy (CBT-E),
suggests that the processes maintaining each eating disorder are largely the same
across disorders. As a result, there is considerable overlap in symptom presentation
and targets for interventions. For example, a fundamental characteristic of both AN
and BN is the overvaluation and disturbed perception of weight and shape (APA,
2022), a feature which must be addressed in treatment regardless of the specific
diagnosis or type of treatment implemented. Additionally, binge eating among
those with BN and BED is often triggered by negative mood and is maintained by
temporary relief from undesired mood; therefore, binge eating can be targeted in
treatment with similar approaches across these diagnoses. The transdiagnostic
approach, as asserted by the most recent version of CBT-E, suggests that the symptom
overlap, shared characteristics, and diagnostic fluidity across eating disorders makes
emphasis on the specific diagnosis (i.e., AN versus BN) unnecessary in a treatment
setting (Fairburn et al., 2003; Fairburn et al., 2008). A network analysis provided
additional support for this approach in that symptoms related to overeating, food
avoidance, fullness, and overvaluation of weight and shape were stable across ages for
all eating disorders (Christian et al., 2020).
In addition to the specific eating and body image symptoms, more distal factors
such as interpersonal difficulties are common among patients with eating disorders
(Murphy et al., 2012). These experiences often interact with eating disorder and body
image symptoms and contribute to the development or perpetuation of disordered
eating. Research findings are unclear on directionality, but the data has consistently
demonstrated that individuals with eating disorders endorse less social support than
others (Grisset & Norvell, 1992; Raykos et al., 2014; Tiller et al., 1997). One proposed
 Eating Disorders 141

pathway suggests that the nature of eating disorders (i.e., eating disorders thrive in
secrecy and often are associated with low self-esteem) contributes to social isolation
and therefore less social support over time. Alternatively, it has been proposed that
because the average age of onset is so young (Fairburn et al., 2007), individuals may
not have sufficient time to develop appropriate interpersonal relationships prior to
their illness. Social support has been identified as an important factor in treating eating
disorders as it is associated with both illness severity (Leonidas & dos Santos, 2014)
and recovery trajectory (Goodrick et al., 1999). Additionally, social support has been
highlighted as a key factor in maintaining change following treatment (Linville et al.,
2012), underscoring its importance as a treatment target.
Interpersonal difficulties can also contribute to the perpetuation of eating disorders
in multiple ways. For example, struggling to develop and maintain intimate and social
relationships can worsen self-esteem, which can in turn increase an individual’s
efforts to change their eating behaviors, shape, or weight in order to regain feelings
of control (Fairburn et al., 2003). Additionally, several specific maladaptive eating
behaviors have been associated with difficult social situations. For example, episodes
of binge eating increase following the experience of interpersonal stressors
(Goldschmidt et al., 2014), and dietary restraint increases along with daily and life
event stress (Woods et al., 2010).

Brief Overview of Treatments

Currently, there are three primary evidence-based treatments for eating disorders in
adults: cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and
family-based treatment (FBT). Outpatient CBT for eating disorders typically takes
place over the course of 6 months and includes approximately 20 sessions with the
patient (Fairburn, 2008; Waller et al., 2007). Early stages of treatment focus heavily
on behavioral change to achieve weight restoration or weight stabilization. Focus is
placed on establishing regular eating and reducing other maladaptive weight control
behaviors such as over-exercising or purging. Regular components of treatment
include meal planning, in-session weighing, self-monitoring, and psychoeducation.
After weight has stabilized and disordered eating behaviors have decreased, the
therapist and the patient review progress and focus on more complex patient-
specific treatment goals. These objectives are often identified during the joint formu-
lation at the beginning of treatment and are informed by the transdiagnostic theory by
identifying the factors that maintain a patient’s overvaluation of weight and shape,
such as low self-esteem, perfectionism, difficulties with interpersonal functioning,
and/or poor mood-regulation strategies (Fairburn et al., 2003). Finally, relapse pre-
vention and treatment termination are discussed.
There is strong research support for CBT as an effective treatment for both BN
(Division 12 of the American Psychological Association, 2016a) and BED (Division
142 Loor, Battles, Bennett, Hudson, and Whisenhunt

12 of the American Psychological Association, 2016b; Hilbert et al., 2019). A recent

literature review and meta-analysis found that CBT was more efficacious than other
psychotherapies for individuals with BN and BED (Linardon et al., 2017). This meta-
analysis involving CBT strengthens the approaches’ evidence base to be more
consistent with the Tolin criteria (Tolin et al., 2015). Linardon and colleagues
(2017) found greater improvements with CBT compared to IPT for behavioral (e.g.,
bingeing and/or purging episodes) and cognitive (e.g., concern about weight, shape,
or eating) symptoms at posttreatment, and for cognitive symptoms longitudinally.
Additionally, CBT was found to be more effective in decreasing behavioral symptoms
in BED than was behavioral weight loss (Linardon et al., 2017). However,
a subsequent meta-analysis found IPT to produce the highest abstinence rates
(Linardon, 2018). In addition, the results of this meta-analysis indicated that race or
ethnicity was not associated with the cessation of binge eating, thus suggesting BED
has good effects with underrepresented groups, another important aspect of the Tolin
criteria (Cougle & Grubaugh, 2022; Tolin et al., 2015).
The research support for AN is less consistent. Currently, the research support for
CBT for AN is classified as modest for post-hospitalization relapse prevention but
controversial for acute weight gain (Division 12 of the American Psychological
Association, 2016c). Instead, a recent literature review suggests enhanced cognitive-
behavioral therapy (CBT-E) may be promising for individuals with AN. More
specifically, Atwood and Friedman (2020) found that CBT-E was efficacious and
effective at reducing eating disorder behaviors across all diagnostic categories and for
increasing BMI in individuals with AN. However, there was not strong evidence to
establish superiority of CBT-E over comparison treatments, particularly in the long-
term (Atwood & Friedman, 2020). Overall, additional research is needed, ideally
studies that address the Tolin criteria, to clarify the effectiveness for specific eating
disorders and improve the overall efficacy of CBT for eating disorders.
Family-based treatment (FBT) is another treatment option for eating disorders.
FBT for AN and BN has considerable research support confirming its efficacy for
treating adolescents (Lock, 2011; Lock, 2015). However, recent studies have exam-
ined the possibility of adapting FBT for use with young adults (FBTY) and have found
some support (Chen et al., 2016). For FBT with young adults, there is more flexibility
in choosing a nonparent support figure to be in charge of refeeding (i.e., in order to
achieve weight restoration, set amounts of foods are fed at scheduled times during
the day), and developmentally appropriate levels of independence are considered. In
both FBT and FBTY, the focus is on weight restoration, which is achieved through
parental empowerment. A nonblaming stance and an intentional separation of the
illness from the patient are both hallmarks of FBT (Lock & Le Grange, 2015).
Typically, outpatient treatment lasts for 20 sessions and consists of three phases. In
phase 1, parents are put in charge of weight restoration. In phase 2, the patient
gradually takes over control of their eating, and phase 3 focuses on fostering
 Eating Disorders 143

autonomy. Currently, FBT for AN is considered to have strong research support

(Division 12 of the American Psychological Association, 2016f) while FBT for BN
is considered to have modest research support (Division 12 of the American
Psychological Association, 2016g). However, the majority of the research support
is for traditional FBT designed for adolescents. Initial research examining its efficacy
in young adults has shown promise (Chen et al., 2016), though more research is
needed.
Interpersonal Psychotherapy (IPT) is a treatment that does not focus on the
symptoms of the ED, but instead on interpersonal difficulties in a patient’s life as it
is thought that these difficulties contribute to the onset and maintenance of the eating
disorder (Wilson et al., 2010). IPT was originally created for patients with depression,
with a focus on four domains: role disputes, role transitions, interpersonal deficits, and
unresolved grief. Instead of a focus on disorder-specific symptoms, the focus of IPT is
on the interpersonal context and is hypothesized to promote positive changes by
increasing social support, reducing interpersonal stress, promoting emotional pro-
cessing, and enhancing interpersonal skills (Lipsitz & Markowitz, 2013). Outpatient
IPT typically lasts 20 weeks, can be administered in an individual or group format,
and consists of three primary phases. In phase 1, the patient and therapist work
together to identify which interpersonal problems should be the focus of treatment.
In phase 2, the emphasis is on the patient taking the lead in facilitating interpersonal
change. Phase 3 is focused on maintenance of improvements and relapse prevention.
Currently, there is strong research support for the efficacy of IPT for BN (Division 12
of the American Psychological Association, 2016d) and BED (Division 12 of the
American Psychological Association, 2016e). While CBT produced greater initial
changes, a literature review found that IPT led to improvements occurring later and
maintained over time for patients with BN (Miniati et al., 2018). Additionally,
research has shown that group IPT for BED is effective in reducing binge episodes
posttreatment and longitudinally (Miniati et al., 2018).

Credible Components of Treatments

Psychoeducational Strategies
Psychoeducation is utilized across CBT-E, FBT, and IPT as a tool to (1) explain the
etiology of the condition and provide a rationale for the treatment approach, and (2)
build motivation. In both CBT-E and FBT, patients and/or families are educated on
the causes of eating disorders and the severity of ED symptoms (Dalle Grave et al.,
2019; Fairburn, 2008). For CBT-E, this information is used to collaboratively create
an individualized case formulation of the patient’s eating disorder symptoms
(Fairburn 2008). This formulation emphasizes the role of overvaluation of weight
and shape in the maintenance of problematic eating behaviors (e.g., restriction,
144 Loor, Battles, Bennett, Hudson, and Whisenhunt

bingeing). This formulation may also incorporate the influence of individuals’ mood
and adverse life events in the maintenance cycle of eating disorders. It is key that
patients understand their individualized case formulations (Bailey-Straebler et al.,
2022). Patients are encouraged to see their eating disorder as something they can
control, and case formulations are used to show patients how they can gain control
over the course of treatment.
For FBT, initial psychoeducation on the eating disorder presentation serves as
a reminder of the seriousness of the eating disorder and is used as a call for action with
the parents of the patient (Dalle Grave et al., 2019). Emphasis is placed on seeing the
eating disorder as separate from the patient. The patient is seen as not in control of
their eating disorder. This approach contrasts with CBT’s approach to psychoeduca-
tion, and it allows parents to work on treating the eating disorder rather than the
patient while helping reduce blame on the parents or the patient. Parents are encour-
aged to take control of the patient’s eating during the initial stages of treatment until
healthy eating patterns can be established.
IPT diverges from FBT and CBT-E by emphasizing current interpersonal problems
that maintain eating disorder symptoms rather than discussing the onset of the eating
disorder (Murphy et al., 2012). Research on interpersonal models for eating disorders
has found that interpersonal problems and low self-esteem are associated with eating
pathology (Ivanova et al., 2015; Lampard et al., 2011; Raykos et al., 2017). Therefore,
initial psychoeducation focuses on how interpersonal problems can exacerbate eating
disorder symptoms such as bingeing or restriction. Patients are informed that adverse
interpersonal events can lead to worsened self-esteem, which contributes to eating
disorder symptoms over time. Consequently, resolving interpersonal problems rather
than the eating disorder symptoms is the focus of IPT. Patients receive information
about common interpersonal problems that lead to eating disorder symptoms such as
grief, interpersonal role disputes, role transitions, interpersonal deficits, and life goals.

Nutritional/Dietary Strategies
Nutritional/dietary strategies comprise a key domain of most effective psychothera-
pies for eating disorders, with some dietitians advocating for even more focus on
malnutrition and dietary care within treatment manuals (Jeffrey & Heruc, 2020).
Because IPT indirectly targets eating behavior, dietary strategies are not utilized in
treatment. In contrast, both CBT-E and FBT utilize dietary strategies early in treat-
ment with the goal of weight stabilization and reinforcement of regular eating (Dalle
Grave et al., 2019). In CBT-E, patients begin monitoring their eating behavior within
the first few treatment sessions (Fairburn, 2008). Self-monitoring of eating is seen as
an essential component of CBT-E (Bailey-Straebler et al., 2022) and one of the
primary mechanisms of change in reducing binge eating frequency because it
increases awareness of eating behavior patterns and provides data that helps therapists
 Eating Disorders 145

Box 9.1 Body Checking and Body Avoidance

For many patients, body checking and body avoidance play a major role in the
maintenance of disordered eating (Nikodijevic et al., 2018). Body checking behaviors
include activities such as frequent weighing, looking in the mirror, or feeling and
pinching areas of the body. Regardless of the information gained from these behaviors
(e.g., lost or gained weight), individuals with eating disorders interpret information in
a way that strengthens their overreliance on weight and shape as primary determinants
of their mood and self-esteem. For example, if weight has increased, they may feel guilty
and anxious and make plans to further restrict their eating, and if weight has decreased,
they may become more determined to engage in more restriction and body check more
frequently. Body avoidance can include not looking in mirrors, wearing only baggy
clothing, and avoiding being weighed. These behaviors also maintain disordered eating
by enhancing anxiety and fear associated with body weight and shape.

work effectively with patients to establish regular eating schedules (Sivyer et al.,
2020). Patients monitor their daily food intake (i.e., amount eaten and when; however,
patients do not monitor caloric intake) and frequency of binges or purges. Each eating
event is monitored in the context of time of day and thoughts and feelings associated
with eating (Fairburn, 2008). Therapists often work with patients to establish a regular
schedule of eating (e.g., three meals a day with two snacks) with the goal of disrupting
previously held dietary rules.
In FBT, parents have the primary control of changing their adolescent’s eating
patterns. It is largely up to the parents how and when adolescents eat, and the therapist
serves as a consultant as needed (Kosmerly et al., 2015). Weight restoration is the first
goal established in FBT, and parents are encouraged to use whatever means they find
helpful to change the adolescent’s eating. While parents can choose to record their
adolescent’s eating behavior, it is not required. Once weight has been restored,
adolescents regain control over their eating patterns.

Behavioral Strategies
Behavioral strategies form a fundamental component of effective eating disorder
treatments. While numerous behavioral techniques are used, there are three core
strategies: exposure therapy, social support and in-session weighing.

Exposure Therapy
Exposure interventions have been demonstrated to be an effective component of
eating disorder treatments and have been linked to decreased body dissatisfaction,
decreased food-related anxiety, and increased BMI in those with AN (Butler &
Heimberg, 2020). Exposures may encompass a variety of formats and targets
146 Loor, Battles, Bennett, Hudson, and Whisenhunt

depending on a patient’s presentation. For example, body-image-focused exposures

can incorporate mirrors or videos where individuals view themselves and confront
negative thoughts, emotions, and body sensations that arise (Griffen et al., 2018).
These exposures support more realistic body size perceptions, improve body image,
and reduce body checking and avoidance (Butler & Heimberg, 2020; Griffen et al.,
2018). These improvements are important as seeing one’s body in a more flexible way
instead of avoiding disliked areas is tied to better treatment outcome (Pellizzer et al.,
2018). Food exposures involve highly feared or avoided foods and/or eating situ-
ations. Studies from across the fields of anxiety and eating disorders have demon-
strated that individuals must experience exposure to feared situations while reducing
their use of safety behaviors to maximize the effectiveness of exposure therapy
(Butler & Heimberg, 2020; Reilly et al., 2021). Therefore, therapists help patients
to eat feared foods while limiting the use of safety behaviors (e.g., cutting food into
small pieces, counting calories, avoiding certain types of foods). Many studies on
food exposures are conducted with patients enrolled in more intensive hospitalization-
based programs and are associated with positive outcomes (e.g., increased caloric
intake/BMI and decreased anxiety; Butler & Heimberg, 2020). Virtual reality expos-
ures have been increasingly used to expose individuals to a variety of environments,
such as places where individuals typically binge eat or places that contain foods that
provoke high anxiety. Further research is needed to determine how this approach
functions compared to corresponding in vivo therapeutic approaches (Butler &
Heimberg, 2020).

Social Support
Many therapeutic approaches incorporate an individual’s social network by actively
involving family and significant others in the treatment. This strategy is used espe-
cially when family members or significant others might be of particular help to
patients or when they are making changes more difficult for patients (Fairburn,
2008). Family members or significant others involved in treatment can learn ways
to best support patients in treatment, strategies for handling repeated reassurance-
seeking, and approaches to help patients with decisions about when and what to eat
(Fairburn, 2008; Mason et al., 2016).
FBT in particular has a more central role for family and significant others, and
although FBT was originally designed for the treatment of adolescent eating dis-
orders, it is also used with young adults with several adaptations. Adaptations include
allowing individuals to choose a support adult to be involved in treatment that may or
may not be a parent (Chen et al., 2016). Support adults are involved throughout
treatment and assist in actively planning and eating meals with patients. Although
weight restoration is still a primary objective, young adults in this treatment generally
have more choice compared to adolescents in making decisions such as returning to
 Eating Disorders 147

activities like college, where to have meals, and options for individual therapy
sessions, although support adults take a more active role when weight restoration
goals are not being met (Chen et al., 2016).

In-Session Weighing
In-session weighing is a common component across effective treatments for eating
disorders, while some treatments emphasize its use to a greater degree (e.g., central
and nonnegotiable aspect in most treatments for AN, and “advisable” in IPT for BED;
Waller & Mountford, 2015). Typically, patients are asked not to weigh without the
presence of a treatment provider. Patients are generally weighed weekly or at every
session depending on their severity. The weight or change in weight from the previous
weighing is shared with the patient with an emphasis on interpreting several sessions’
readings in order to focus on trends rather than overinterpretation of individual
readings, which may vary for a variety of reasons (e.g., recency of eating, water
intake, proximity to next menstrual cycle, etc.; Fairburn, 2008). Regular weighing
allows therapists to best address patient safety and understand changes in eating
patterns (Waller & Mountford, 2015). Additionally, this approach reduces anxiety
associated with weight and modifies unhelpful cognitions regarding weight (e.g.,
“regular meals and/or eating certain types of foods will lead to immense unstoppable
weight gain”; Waller & Mountford, 2015).

Cognitive Strategies
Cognitive strategies utilized in eating disorder treatments focus on noticing and
changing negative thought patterns, typically about the importance of shape and
weight (Palmieri et al., 2021; Tatham et al., 2015). Biases in thinking, such as black-
and-white thinking, are common, and a therapist works with a patient to identify these
unhelpful patterns and find more effective ways to approach difficult situations such
as mealtimes. In particular, CBT-E focuses less on cognitive approaches (e.g.,
conventional thought records, identifying core beliefs) and more on helping patients
make and sustain behavioral changes (Fairburn, 2008). This is especially true for
earlier stages of treatment where gaining or stabilizing weight is the number one
priority. After weight has been stabilized, more attention is then focused on how
thinking patterns contribute to eating disorder symptoms.
A primary goal of effective treatments for eating disorders is to reduce the import-
ance of shape and weight in a patient’s life. In CBT-E, patients create a pie chart to
illustrate the areas of their lives that impact their self-evaluation (e.g., family, work,
school; Fairburn, 2008; see also Geller et al., 1997). Those with eating disorders
typically have their self-evaluations primarily driven by their shape, weight, and
eating. Once represented visually, the consequences of an overreliance on shape,
weight, and eating are discussed. For example, patients may identify consequences
148 Loor, Battles, Bennett, Hudson, and Whisenhunt

such as how their lives feel controlled by shape and weight to the point where other
formerly important aspects do not seem to matter anymore. Next, goals are set for
reducing the importance of shape and weight, along with increasing the importance of
other domains (e.g., strengthening interpersonal relationships, gaining or returning to
hobbies).

Relapse Prevention Strategies

The final stage in eating disorder treatment across modalities typically includes
a focus on relapse prevention. This focus is particularly important for those recovering
from eating disorders given the higher rates of relapse and potential triggers following
treatment (Heruc et al., 2020; Mares et al., 2022; Steinglass et al., 2022). First, the
therapist and patient collaboratively take stock of progress made in treatment. Next,
they create a plan to help the patient maintain positive changes once treatment ends.
Relapse prevention plans are frequently multifaceted. They include the identification
of relevant disordered behaviors or changes in patient functioning that would indicate
risk of relapse such as frequent body checking, rigid dietary rules, or unhealthy weight
control behaviors (Fairburn, 2008; Le Grange & Lock, 2007). Next, they work
together to identify upcoming life events or potential scenarios that might be high-
risk for weight or eating related concerns (e.g., food-driven holiday celebrations, or
wearing a swimsuit at a community pool). The therapist and patient work together to
create a plan for how the patient will use skills learned in therapy to manage the events
and reduce overall risk of relapse.

Approaches for Youth

Adolescents treated for eating disorders tend to have better outcomes than do individ-
uals entering treatment as adults, perhaps because of their shorter duration of illness
(Lock, 2015; Mairs & Nicholls, 2016). While many components of efficacious
approaches are similar for children, adolescents, and adults, there are also some
important distinctions and areas of focus. FBT is the leading and most widely
researched approach for adolescents (Dalle Grave et al., 2019; Lock & Le Grange,
2019; Mairs & Nicholls, 2016). FBT for children and adolescents focuses on parents
taking charge of a child’s eating, with initial goals of weight restoration or stabiliza-
tion and the disruption of eating disorder behaviors (Lock & Le Grange, 2015).
Compared to adult treatment, FBT for children and adolescents relies more on
parental control over their child’s eating with a gradual shift of independence back
to the child that takes appropriate developmental trajectories into account. In FBT,
adolescents are viewed as being separate from and controlled by the eating disorder,
which results in the individual appearing to function as a much younger child in terms
of emotional and social development. Instead of being blamed for causing the eating
 Eating Disorders 149

disorder, parents are seen as allies in fighting back against the eating disorder (Lock &
Le Grange, 2015). The body of efficacy research on FBT has led most clinical
guidelines to recommend FBT as the first line of treatment for child and adolescent
eating disorders (Lock & Le Grange, 2019).
Newer evidence suggests that CBT-E adapted for adolescents is an effective
alternative treatment to FBT (Dalle Grave et al., 2021; Le Grange et al., 2020).
Although more research in adolescent samples is still needed, including randomized
controlled trials, initial results are promising. CBT-E for adolescents is mostly similar
to CBT-E for adults, in that eating disorders are viewed as belonging to the individual,
and patients are actively involved in treatment from the onset and encouraged to take
back control over their lives using cognitive and behavioral strategies (Dalle Grave &
Calugi, 2020; Dalle Grave et al., 2019). Compared to CBT-E for adults, parents play
a larger role, although their role is limited to helping the adolescent pursue goals
toward behavior change (Dalle Grave et al., 2019).

Other Variables Influencing Treatment

Assessment and Diagnosis
Assessment measures are used for eating disorder screening, diagnosis, and evalu-
ation of treatment progress. Assessments may be administered as either structured or
semistructured interviews or paper-and-pencil formats. Challenges of eating disorder
assessment include the stigma, ambivalence about symptom reduction, and secretive
nature of eating disorders that can prompt denying, hiding, or minimizing symptoms.
Furthermore, the selection of appropriate eating disorder assessment measures and
careful review of results is important to consider, especially when measures are used
across different groups. For example, many eating disorder measures were developed
using fairly homogenous samples and may be more or less useful when applied to men
or non-White groups where symptom presentation and appearance ideals may differ
(Belon et al., 2015; Darcy & Lin, 2012; Kelly et al., 2012). Sufficient and accurate
assessment prior to and during treatment is crucial for correctly identifying the
severity of the disorder and providing appropriate recommendations about the level
of care needed. Finally, regular assessment of treatment progress throughout treat-
ment is essential. Regular assessments are used to determine if a patient’s symptoms
are improving, and this data influences treatment by identifying areas in need of focus
in treatment. Additionally, assessment data is used to make decisions on when
treatment should be terminated.
Patients may have features of an eating disorder without necessarily meeting
criteria for an eating disorder diagnosis. Assessment is used to distinguish subclinical
versus clinically significant eating disorders to assist with treatment planning.
In many patients with subclinical eating disorders, individual and intensive
150 Loor, Battles, Bennett, Hudson, and Whisenhunt

psychotherapy may not be warranted, and a stepped-care model is more favorable (Le
Grange et al., 2021; Wilson et al., 2000). For example, subclinical BED may be
effectively treated with guided self-help CBT-E (Traviss-Turner et al., 2017). Patients
read self-help materials while meeting infrequently (e.g., once every few weeks) with
a therapist. Guided self-help CBT-E has also been adopted for delivery over telehealth
increasing patient access to treatment (Jensen et al., 2020). Patients with subclinical
eating disorders may also be an appropriate fit for outpatient group treatment
(Fairburn, 2008); however, many factors will influence patients’ decision to pursue
group intervention (e.g., patient preference, group availability).

Comorbidity
Comorbidity is seen as the rule rather than the exception within eating disorders
(Fairburn, 2008; Momen et al., 2022). The most recent literature shows a high
prevalence of comorbid mood and anxiety disorders, substance use (Keski-
Rahkonen, 2021), PTSD (Ferrell et al., 2022), and obsessive-compulsive disorder
(Mandelli et al., 2020) among patients across the lifespan (Convertino & Blashill,
2021). Consequently, a thorough psychiatric assessment is recommended prior to
beginning eating disorder treatment. When comorbid disorders are identified or
suspected, it is helpful to discern which features of these comorbid disorders are
treatment-interfering versus those that may be alleviated post-eating-disorder
intervention. For example, Fairburn (2008) recommends that if clinically signifi-
cant depression is identified during the CBT-E assessment, depression treatment
should precede eating disorder intervention. There are specific features of depres-
sion (e.g., poor concentration) that directly interfere with treatment adherence and
may be best addressed prior to working with the eating disorder. However, there
are no data to suggest which order of treatment would be most effective with
comorbid depression and eating disorders. Some comorbid disorders do not
necessarily interfere with eating disorder treatment, and in these situations it is
recommended that the therapist and patient work together to prioritize treatment
goals. For example, patients diagnosed with comorbid PTSD may decide to
complete trauma-related treatment first depending on the functional impact of
trauma versus eating disorder symptoms.

Demographics
For many decades, eating disorders were believed to primarily exist within White,
young, wealthy females. Emerging evidence shows that eating disorders exist among
patients of every age, race/ethnicity, gender, socioeconomic status, sexual orientation,
ability status, and so forth (Mitchison et al., 2014). Unfortunately, the assessment of
eating disorders is only now catching up to this new evidence. Many of the commonly
 Eating Disorders 151

used diagnostic measures (e.g., the Eating Disorder Examination – Questionnaire)

were exclusively validated within a homogenous population (Fairburn & Beglin,
1994). Recent research shows that the cut-off scores for several of these measures
may need to be adjusted based on demographic variables (Schaefer et al., 2018).
Therefore, it is important to research the most up-to-date norms on commonly used
measures and use norms specific to patients’ demographics. Clinicians should also
acknowledge the limitations of these assessments as many may not capture culturally
relevant influences on diagnostic criteria. For example, in some Black communities,
a larger body size is seen as more beautiful (Awad et al., 2015; Watson et al., 2019);
however, many assessments for eating disorders primarily ask about a drive for
thinness. Researchers are beginning to understand that eating disorder symptomatol-
ogy varies greatly across populations and further work is needed to adapt assessment
procedures accordingly.

Medication
Research into pharmacotherapy has been met with mixed levels of support for
different EDs. First, there are no current medications approved for the treatment
of AN and no medication has been found to be effective to either promote sustained
weight gain or to alleviate underlying psychopathology (de Vos et al., 2014; Mayer,
2017). In contrast, research has supported the use of medications for the treatment of
BN. Specifically, antidepressant medications (selective serotonin reuptake inhibi-
tors [SSRIs]) have been shown to decrease symptoms and reduce frequency of
binge–purge cycles (Mayer, 2017; Svaldi et al., 2019). Due to potential side effects
of medications, psychotherapy alone is often recommended as a first line treatment
for BN, followed by combined psychotherapy with medication. Finally, medica-
tions for BED have differing levels of efficacy depending on which outcome goals
are considered. While the primary goal is often to reduce binge eating, treatments
may or may not also be effective at promoting weight loss. These points are
important to consider as individuals with BED who seek treatment have higher
BMIs and often express weight loss as a treatment goal (Goldschmidt et al., 2011).
Currently, two medications have been shown to be effective for both reducing binge
eating and weight loss: one is an antiepileptic (topiramate) and the other is
a psychostimulant (lisdexamfetamine; Bello & Yeomans, 2018; Hudson & Pope,
2017). Additionally, some antidepressant medications have shown some efficacy in
reducing binge eating but not in promoting weight loss (Hudson & Pope,
2017). Regarding the utility of combining psychological and pharmacological
treatments, only a small minority of randomized controlled trials have shown
a benefit for combining treatments (e.g., Reas & Grilo, 2021). However, these
studies do not provide the level of analysis needed to indicate how medication(s)
may moderate the effects of therapy.
152 Loor, Battles, Bennett, Hudson, and Whisenhunt

Conclusion
Currently, the most studied and efficacious treatments appear to be CBT-E, IPT, and
FBT. Treatments include a number of effective behavioral and cognitive components,
especially focused on strategies addressing nutritional/dietary concerns and weight
restoration. Treatment components also aim to decrease the overemphasis individuals
place on weight, shape, and eating, and allow them to re-engage with other areas of
their lives, including interpersonal relationships. Next steps for these treatments
would include attempts to evaluate the research findings fully against the Tolin
criteria and provide a clear recommendation of very strong, strong, or weak, using
the transparent grading guidelines (Tolin et al., 2015).

Useful Resources

Websites
• Association for Size Diversity and Health: https://asdah.org/health-at-every-size-haes-approach/
• Australia & New Zealand Academy For Eating Disorders: www.anzaed.org.au/
• The National Eating Disorders Association: www.nationaleatingdisorders.org/

Books
• Bacon L. (2010). Health at every size: The surprising truth about your weight (Revised &
updated ed.). BenBella Books.
• Brown H. (2010). Brave girl eating: A family’s struggle with anorexia. William Morrow.
• Covington Armstrong, S. (2009). Not all Black girls know how to eat: A story of bulimia.
Lawrence Hill Books.
• Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
• Fairburn, C. G. (2013). Overcoming binge eating: The proven program to learn why you
binge and how you can stop (second ed.). Guilford Press.
• Forsberg, S., Lock, J., & Le Grange D. (2018). Family based treatment for restrictive eating
disorders: A guide for supervision and advanced clinical practice. Taylor and Francis.
• Waller, G., Turner, H. M., Tatham, M., Mountford, V., & Wade, T. (2019). Brief cognitive
behavioural therapy for non-underweight patients: CBT-T for eating disorders. Routledge.

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 10
Insomnia Disorder
Parky Lau, Onkar Marway, and Colleen Carney

Insomnia Disorder (ID) is characterized by trouble falling asleep, staying asleep, or

both, occurring three nights a week or more. The sleep disturbance must be accom-
panied by impairment in functioning or distress about the sleep issue. ID is conceptu-
alized as a 24-hour disorder, or a “sleep-wake” disorder (i.e., ID causes problems in
the daytime in addition to the nighttime). Importantly, ID is chronic, so the issues
must be present for three months or more to meet criteria for the condition as outlined
in the DSM-5-TR (American Psychological Association, 2022). The target symptom
is the sleep complaint, as well its impact on daytime functioning, but the target
behaviors are derived from what causes chronic insomnia. Science-based treatments
operate by targeting behaviors and cognitions that are theorized to perpetuate
insomnia. We will discuss these targets in greater detail in the ensuing etiology
section, but briefly, to address chronic insomnia, treatment aims to re-associate the
bed with sleeping, decrease sleep effort behavior, restore sleep self-efficacy, increase
the drive for deep sleep, regulate the circadian system, and modify beliefs that get in
the way of sleep unfolding naturally.

Etiology and Theoretical Underpinnings of Treatment

Several models have been helpful in understanding insomnia; these include the
cognitive model of insomnia and the 3P model. The cognitive model of insom-
nia (Harvey, 2002) theorizes that people with insomnia tend to be excessively
worried about their sleep and the potential daytime consequences of not getting
enough sleep. This negatively toned cognitive activity increases autonomic
arousal and distress, which leads to selectively attending to and monitoring of
external and internal evidence of sleep deficit (e.g., feeling tired, poor concen-
tration). As a well-intentioned attempt to compensate for perceived sleep deficits
and reduce anxiety, people with insomnia engage in counterproductive safety
behaviors (e.g., thought control, limiting/canceling plans and activities, going to
bed early). Unfortunately, these behaviors maintain anxiety and disrupt the
159
160 Parky Lau, Onkar Marway, and Colleen Carney

natural processes that govern sleep, which perpetuates the sleep problem. There
is ample literature to suggest that higher negative cognitions lead to more sleep
disturbances (for a review, see Hiller et al., 2015) and one reason for this may
be a result of safety behaviors (Woodley & Smith, 2006). These perpetuating
factors are further elaborated upon in the 3P model proposed by Spielman and
colleagues (1987). The 3Ps are predisposing, precipitating, and perpetuating
factors. Predisposing factors are variables that make a person more vulnerable
to developing chronic sleep problems, such as high trait anxiety and perfection-
ism. These factors interact with precipitating factors (i.e., stressful events that
trigger initial sleep disturbance) to produce acute insomnia (short-term sleep
disturbances). Acute insomnia can become chronic insomnia because of perpetu-
ating factors that maintain sleep disturbances. Specifically, there are physio-
logical (bedtime hyperarousal), psychological (unhelpful beliefs about sleep),
and behavioral (e.g., more time spent resting and reduced activity) factors that
occur during the switch from acute to chronic insomnia (e.g., Bonnet & Arand,
2010; Gehrman et al., 2016; Kay et al., 2016; Riedner et al., 2016).
Psychological interventions are primarily focused on changing specific behaviors
and thoughts that maintain these perpetuating factors, rather than on predispos-
ing or precipitating factors. The main perpetuating factors in ID are conditioned
arousal, a dysregulated clock, and engaging in safety behaviors during the day to
help conserve energy. The model is well-supported through efficacy data in
therapies that employ this model to inform its treatment recommendations,
such as SRT (Spielman et al., 2016).
Treatment of chronic insomnia has been conceptualized and refined based on
our understanding of sleep and wake processes, and its relation with perpetuat-
ing factors of ID. Behavioral sleep medicine leverages this knowledge to target
proposed causes of chronic sleep problems. For example, in the case of ID,
perpetuating factors include diffused homeostatic pressure in the sleep/wake
system (i.e., not enough wakefulness activity during the day to support recovery
sleep), irregular circadian input, and cognitive hyperarousal – the latter of which
can contribute to a learned association between the bed and wakefulness through
excessive time spent in bed awake in a hyperactive state (Perlis et al., 2011).
Given this understanding, behavioral interventions were developed to put pres-
sure on the homeostatic system (e.g., sleep restriction), regularize the circadian
clock (by keeping to regular bed and rise times), and reduce basal and condi-
tioned arousal (e.g., relaxation techniques and stimulus control). It is unsurpris-
ing that science-based behavioral treatments of insomnia have demonstrated high
levels of efficacy and durability because they treat insomnia by disrupting
factors that maintain chronic sleep disturbance.
 Insomnia Disorder 161

Brief Overview of Treatments

There are several consensus statements and clinical guidelines available for ID, and
although there are some minor differences across these statements, all support that the
front-line evidence-based therapy for ID is cognitive-behavioral therapy (CBT-I). For
instance, Boness and colleagues (2020) applied the “Tolin Criteria” (Tolin et al., 2015)
to a systematic review evaluating efficacy of CBT-I. Based on the high-quality evidence
found in support of CBT-I in producing clinically significant effects on insomnia and
other sleep-related outcomes, a strong recommendation toward the use of CBT-I was
merited (see also p. 402 of this book). The most recent clinical guideline comes from
one of the leading authorities on clinical sleep medicine: the American Academy of
Sleep Medicine (AASM) (e.g., Edinger et al., 2021). This taskforce employed the
Grading of Recommendations Assessment, Development and Evaluation (GRADE)
methodology (Guyatt et al., 2008) to systematically evaluate and grade evidence for
psychological treatments for ID. Only those meeting a certain rigor and those with
plausible primary mechanisms made the final list of recommendations, and, of those 11
therapies, CBT-I was the one strong recommendation made by the taskforce.
There is strong evidence to support the efficacy and durability of CBT-I (e.g., Blom
et al., 2016; Johnson et al., 2016). Furthermore, patients prefer psychological interven-
tion over medication (McHugh et al., 2013), and CBT-I is generally preferred to other
types of behavioral interventions for insomnia (Sidani et al., 2009). The cognitive
components of CBT-I consist of restructuring unhelpful and rigidly held beliefs about
sleep and can consist of the use of thought records, Socratic questioning/guided self-
discovery, and behavioral experiments to challenge beliefs. The behavioral components
of CBT-I consist of sleep restriction therapy (SRT), stimulus control, sleep hygiene, and
occasionally relaxation therapy. The first session of CBT-I generally consists of
psychoeducation of the sleep systems (i.e., the two-process model of sleep regulation;
Achermann, 2004) and how we can leverage this knowledge to help the individual get
their sleep back on track. Specifically, the two-process model includes Process S, which
refers to the homeostatic sleep/wake system that builds up pressure for sleep the longer
we are awake, and Process C, the circadian pacemaker that reflects our internal daily
rhythms over a near 24-hour cycle and is independent of sleep/wake history. When
harmonized, these processes interact to produce robust timing of sleep and waking.
Each session is guided by continuous sleep diaries kept by the patient between
sessions. SRT primarily consists of matching an individual’s time in bed to their
average total sleep time (Glovinsky & Spielman, 1991). This is done in an attempt to
increase the individual’s sleep efficiency. Stimulus control consists of breaking the
conditioned association between bed and wakefulness (Bootzin, 1972) by being in bed
only when asleep, or when sleep is likely to occur. Relaxation therapies (e.g., progres-
sive muscle relaxation, guided imagery meditations) have also been used to combat
hyperarousal to support a physical state that is more compatible with sleep.
162 Parky Lau, Onkar Marway, and Colleen Carney

Credible Components of Treatments

Stimulus Control
Stimulus control was originally a single-component behavioral therapy for chronic
insomnia designed to extinguish the association between the bed/bedroom and
wakefulness to restore the association of bed/bedroom with sleep (Bootzin, 1972).
The associated set of instruction include: (1) go to bed only when sleepy, (2) get out
of bed when unable to sleep, (3) use the bed/bedroom for sleep and sex, (4) wake up
at the same time every morning irrespective of the previous night’s sleep, and (5)
refrain from daytime naps. Stimulus control was created using learning principles to
address research-derived maintaining factors (e.g., conditioning). For example,
stimulus control leverages principles of associative learning by instructing the
person to go to bed only when sleepy and to get out of bed when sleep is not coming.
Through these principles, the bed reacquires stimulus value for sleep (Perlis et al.,
1997). In support of the theoretical utility for stimulus control, empirical data
implicate the existence of a maladaptive paired association between the bed
and arousal in ID. For example, Robertson et al. (2007) found that people with
insomnia tend to report more cognitive arousal and less sleepiness within the
bedroom environment at lights out (i.e., bedtime) compared to good sleepers.
Consequently, there is a need to restore paired associations in the bedroom environ-
ment that are conducive to sleep rather than wake.
Beyond principles of learned associations, stimulus control instructions also lever-
age the circadian system by creating a regular rise time. This also leverages the
homeostatic system by delaying bedtime until sleepy and increasing time out of
bed. These two behaviors indirectly increase pressure for sleep by reducing resting
behavior.
There is strong theoretical backing to support stimulus control as a treatment of
chronic insomnia, and empirical data supports its efficacy. Initial practice param-
eters (Chesson et al., 1999) found the strongest evidence for stimulus control, and
subsequent reviews of the evidence have continued to recommend stimulus control
as a treatment for ID (Morgenthaler et al., 2006). Randomized controlled trials
indicate that stimulus control is an effective intervention for improving sleep indices
(e.g., sleep latency, wake after sleep onset) (Lacks et al., 1983; Ladouceur &
Gros-Louis, 1986) and sleep quality (Harris et al., 2012), in addition to perceived
insomnia severity (Sidani et al., 2019). The AASM GRADE assessment of stimulus
control found low-quality evidence for its efficacy, due to imprecision (i.e., confi-
dence intervals not meeting clinical significance) and risk of bias, such as issues of
blinding, allocation concealment, and selective reporting of results (Edinger et al.,
2021). More up-to-date high-quality research is needed to support stimulus control
as an effective monotherapy for ID, but it is currently considered one of the main
effective components of CBT-I.
 Insomnia Disorder 163

Sleep Restriction Therapy

Numerous studies have shown support for SRT as a treatment for insomnia. Early
studies compared SRT to other components of CBT-I in RCTs and, generally, these
studies repeatedly showed that SRT was comparable to CBT-I or other components of
CBT-I and superior to sleep hygiene (Epstein et al., 2012; Fernando et al., 2013;
Friedman et al., 2000). SRT and stimulus control are both highly effective, but
combining them into a multicomponent CBT-I produces the best remission rates
and largest effects (Maurer & Kyle, 2022). At the same time, there is research to
the contrary. For example, Sidani et al. (2019) conducted a randomized controlled
trial comparing sleep hygiene, stimulus control, SRT, and CBT-I which combines all
treatment methods studied. The researchers found that individuals in the sleep
hygiene group showed the least response to treatment and that stimulus control and
SRT showed higher rates of remission relative to multiple-component therapy.
SRT is hypothesized to function by increasing homeostatic pressure to sleep by
limiting time in bed to an individual’s mean total sleep time. This increased sleep
pressure decreases sleep onset latency and wake after sleep onset. It may also,
indirectly, reduce pre-sleep arousal by increasing sleep pressure (Maurer et al.,
2022). Although establishing a regular time in bed can be seen as leveraging the
circadian system, Maurer et al. (2020) found that compared to setting a regular
bedtime and rise time, SRT produces superior reductions in insomnia symptoms.

Relaxation Therapies
Relaxation therapies are occasionally included in CBT-I when patients report trouble
with high cognitive arousal or somatic tension. Patients are encouraged to use relax-
ation strategies throughout the day, outside of the bedroom environment, to help
decrease symptoms of daytime anxiety. These methods may include progressive
muscle relaxation (PMR), breathing exercises, or guided imagery. Studies support
the use of relaxation therapies as a potentially beneficial component of CBT-I. There
are several studies supporting relaxation therapies for insomnia (e.g., PMR, medita-
tion, and autogenic training) (Greeff & Conradie, 1998; Means et al., 2000; Nicassio
& Bootzin, 1974; Woolfolk et al.,1976).
There are few studies comparing relaxation therapies directly to CBT-I or other
components of CBT-I. Espie and colleagues (1989) reported that patients receiving
PMR did not improve as much as did those receiving stimulus control; similarly, Morin
and Azrin (1988) reported that stimulus control was superior to imagery training in
reducing wake after sleep onset. Edinger et al. (2001) reported that CBT-I significantly
outperformed PMR, and those in the CBT-I condition showed a greater reduction in
wake after sleep onset and increase in sleep efficiency at posttreatment. Rybarczyk et al.
(2002) compared CBT-I to a relaxation-based treatment and waitlist control in 28 older
adults with insomnia. The CBT group fared better, with 54% of individuals in the CBT
164 Parky Lau, Onkar Marway, and Colleen Carney

Box 10.1 Components Requiring Further Research

Some components that require further research include mindfulness, intensive sleep
retraining, paradoxical intention, and sleep hygiene. Mindfulness approaches are used
as a form of meditation, which emphasizes a nonjudgmental state of complete
awareness of one’s internal and external experience in the present moment. Meta-
analytic results suggest that mindfulness meditation may significantly improve certain
sleep indices (e.g., sleep quality, total wake time) but not others (e.g., subjective
insomnia severity, unhelpful beliefs about sleep, total sleep time) (Gong et al., 2016).
One study found that incorporating mindfulness meditation with behavioral strategies
(e.g., SRT) led to greater rates of insomnia remission and response compared to
mindfulness-based stress reduction (Ong et al., 2014). Consequently, mindfulness
meditation may be particularly helpful as part of a multicomponent therapy.
Intensive Sleep Retraining (ISR) is a newly described treatment designed to
markedly increase homeostatic sleep pressure using acute sleep deprivation to reduce
sleep onset difficulties and sleep-state misperception (Edinger et al., 2021; Lack et al.,
2019). After the use of an acute sleep deprivation, the treatment facilitates a series of
rapid sleep onsets to counteract the conditioned insomnia response. The theory is that
people with insomnia will begin to better recognize feelings of sleepiness and see the
bed as opportunity to obtain much needed sleep rather than a place of fear. Given the
relative novelty of this treatment, there is less empirical evidence regarding its efficacy,
though research is promising. For example, preliminary investigations have found that
ISR significantly improves nighttime and daytime symptoms of insomnia (Harris et al.,
2007).
In paradoxical intention, the patient purposefully engages with the feared activity
(i.e., staying awake) to reduce performance anxiety and conscious intent to sleep that
counterintuitively impacts the desired outcome (i.e., falling asleep). One study found
a reduction in sleep onset latency and number of nighttime awakenings in favor of the
paradoxical intention group (Ascher & Turner, 1979), but other studies have not
provided support (Lacks et al., 1983). Overall, a GRADE assessment of “very low” for
quality of evidence supporting this treatment was provided by the AASM (Edinger et al.,
2021). The current data does not support paradoxical intention as a stand-alone
intervention for chronic insomnia, though paradoxical intention is listed by the
American Psychological Association Division 12 Task Force as having “strong research
support” under the original (1993) criteria (Division 12, 2022).
Sleep hygiene is integrated into CBT-I but does not have an empirical base as
a stand-alone treatment for insomnia. Studies repeatedly show that sleep hygiene is
inferior to SRT, stimulus control, and CBT-I as a whole (Chung et al., 2018). Sleep
hygiene consists of education about several factors or habits that can be sleep
disruptive or interfering, such as curbing intake of substances with effects on sleep
microarchitecture (e.g., caffeine, alcohol, cannabis) close to bedtime and having a sleep
environment that is conducive to sleep (e.g., comfortable temperature, dark, limited
noise). Because of the poor evidence base, despite an unfortunate common use as
a monotherapy (e.g., Moss et al., 2013), the AASM advises against its use for ID.
 Insomnia Disorder 165

group experiencing a clinically significant reduction in their insomnia symptoms com-

pared to only 35% and 6% in the relaxation and control conditions, respectively. Thus,
CBT-I is considered a preferable first choice, with the option of combining relaxation
with CBT-I, but relaxation remains an alternative with weaker effects.

Approaches for Youth

Whereas the evidence and treatment described so far has been established in
adults, the approaches for treating childhood sleep problems are similar in their
behavioral methods. There is support for several behavioral treatments, including
unmodified extinction and preventive parent education, graduated extinction, bedtime
fading/positive routines, and scheduled awakenings (Meltzer & Mindell, 2014).
Unmodified extinction consists of ignoring negative behaviors from lights out until
lights on in the morning. Graduated extinction consists of a brief caregiver check-in
after lights out, which decreases in frequency until ignoring negative behavior after
lights out until a set time in the morning. Parental education/prevention provides
caregivers with the sleep information needed to regulate the child’s sleep. Bedtime
fading/positive routines involve a positive bedtime routine, moving the child’s bed-
time later to match when they fall asleep, and stimulus control. Scheduled awakenings
involve waking a child 15–30 minutes before their habitual awakening time and
consoling the child. A meta-analytic review of behavioral interventions in children
supports its efficacy, although perhaps not in those with special needs as available
studies were low (n=2) and statistically significant findings on sleep outcomes were
not found (Meltzer & Mindell, 2014). In pediatric insomnia the treatment relies on the
caregiver for implementing the treatment plan. In general, work with adolescents
involves a delicate balance between parental involvement and the teen implementing
the strategies. CBT-I in teens often involves modifications/additions, such as includ-
ing mindfulness meditation (Bruin et al., 2020), focusing on bedtime electronic habits
(Clarke et al., 2015), or greater parental assistance in treatment (Loring et al., 2016).
Because some studies exclude participants with comorbidities (e.g., Clarke et al.,
2015), our understanding of whether CBT-I is effective in cases where insomnia is not
the only problem is limited. Lastly, because pubescent shifts in circadian rhythms
require special attention when treating sleep disruptions in adolescents (Roenneberg
et al., 2004), other treatments have emerged to address the full range of problems
teens encounter. One such treatment is the Transdiagnostic Sleep and Circadian
Intervention (TranS-C), which combines components of CBT-I along with compo-
nents of circadian interventions like Interpersonal Social Rhythm Therapy – IPSRT
(Harvey et al., 2016), which regularizes daily routines (e.g., sleep/wake cycles,
mealtimes, rest and activity) to strengthen the circadian clock. Randomized controlled
trials of TranS-C in youth have shown promising results (Harvey, 2016; Harvey et al.,
2018), including in a free self-management app called Doze (Carmona et al., 2021).
166 Parky Lau, Onkar Marway, and Colleen Carney

Other Variables Influencing Treatment

Assessment and Diagnosis
Amalgamating data from semi-structured interviews and prospective sleep diaries are
helpful in the assessment of ID. The Consensus Sleep Diary (Carney et al., 2012) is an
integral part of subjective assessment of a subjective disorder. Whereas retrospective
measures such as the Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989) have
affective recall biases (Hartmann et al., 2015), prospective measures capture the
variability inherent in sleep. They assess both habits and subjective experience,
which are key in CBT-I. Reliable data can be obtained from two weeks of sleep
diaries (Wohlgemuth et al., 1999). Questionnaires like the Insomnia Severity Index
(ISI; Morin, 1993) are popular patient-reported outcome measures that can be used to
help track the progress of symptoms throughout and after treatment. Subjective
reports of symptoms are the gold standard because insomnia is a subjective disorder
of sleep complaint. Polysomnography (PSG) data are typically not required or helpful
for the assessment of insomnia. Sleep studies are burdensome and oftentimes lead to
over- or underestimations of sleep disturbance. On one hand, individuals may sleep
better in a sleep lab than at home (McCall & McCall, 2012) and this could be because
conditioned arousal is absent in a novel environment. On the other hand, research has
also shown that individuals may sleep more poorly in a laboratory setting (Edinger
et al., 1997) compared to at home. Furthermore, because ID is primarily a disorder of
sleep complaint, PSG data does not contain the presenting complaint: a subjective
dissatisfaction with sleep quality. PSG studies are helpful for differential/additional
diagnosis only (e.g., sleep apnea, restless legs syndrome).
CBT-I is a treatment meant to address ID only, so diagnosis is an important first
step in deciding whether to use it. Diagnostic interviews for sleep disorders, such
as the Duke Structured Interview for Sleep Disorders (DSISD; Edinger et al.,
2006), offer a reliable and valid approach to differentiating between sleep dis-
orders. This is important as certain sleep disorders can present with symptoms that
are similar to insomnia, but would not respond to insomnia treatment because the
cause of the problem is different. For example, Delayed Sleep Phase Disorder
(DSPD) can appear similar to initial insomnia, as in both sleep problems can lead
to difficulty falling asleep; however, difficulty falling asleep in DSPD is because of
a mismatch between when a person attempts sleep and their body’s circadian
preference for a later bedtime rather than an insomnia problem. CBT-I is not an
effective treatment option for DSPD (Figueiro, 2016; van Geijlswijk et al., 2010).
Other sleep disorders, such as restless legs syndrome and sleep apnea, can also
present with similar symptoms as insomnia but require a different treatment
approach.
 Insomnia Disorder 167

Comorbidity
Insomnia has been described as a prodromal symptom for mental disorders, a feature
of them, and also as a residual symptom that lingers after successful treatment and
can contribute to risk of relapse (Benson, 2015; Fang et al., 2019; Cox & Olatunji,
2020). Meta-analytic studies indicate that the efficacy of CBT-I on insomnia
remains robust across populations with insomnia with comorbid psychiatric and
medical conditions (Wu et al., 2015). However, there are certain comorbidities in
which components of CBT-I, such as sleep restriction, can exacerbate health issues.
For example, sleep restriction is contraindicated in epilepsy because the initial sleep
deprivation from sleep restriction can increase risk for epileptic seizures
(Dell’Aquila & Soti, 2022). Sleep restriction has also been contraindicated in
bipolar disorders because acute sleep deprivation may result in (hypo)manic symp-
toms (Colombo et al., 1999). However, research studying the use of SRT in bipolar
disorder does not support behavioral treatments of insomnia as being harmful to
patients with a bipolar disorder diagnosis (Kaplan & Harvey, 2013). Insomnia is
also frequently comorbid with other sleep disorders. One of the most frequently
studied comorbidities is sleep apnea (Sweetman et al., 2019a). Recent investigations
show that insomnia and sleep apnea can be successfully treated concurrently and
that CBT-I may help increase adherence to sleep apnea treatment (i.e., continuous
positive airway pressure machine use) (Sweetman et al., 2019b; Sweetman et al.,
2020).

Demographics
CBT-I is effective across populations and has demonstrated efficacy across the
lifespan. For example, studies have found improved sleep and health outcomes in
youth (Ma et al., 2018), adults (Natsky et al., 2020), and older adults (Rybarczyk et al.,
2005). Moreover, sex does not appear to impact CBT-I’s efficacy (Cheng et al., 2019),
though more research is needed to understand the interaction between gender/sex and
insomnia. A burgeoning line of research has become focused on treatment outcomes
in minoritized populations, especially considering the impact of race on health
disparities at all levels (Barr, 2014; Simmons et al., 2021). In insomnia, studies
have found that racial discrimination is a significant mediator for sleep health dispar-
ities (Cheng et al., 2020). Although existing research is promising and suggests that
CBT-I demonstrates comparable efficacy across ethnic/racial groups (Cheng et al.,
2019), a fulsome investigation into the role of discrimination in sleep health and
treatment outcomes is needed. Further research should evaluate whether inclusion of
direct therapy work in CBT-I regarding the role of discrimination on sleep health adds
unique value in marginalized populations.
168 Parky Lau, Onkar Marway, and Colleen Carney

Medication
Although behavioral treatments are considered first-line, it is important to mention
pharmacotherapy as a treatment for insomnia and other sleep disorders. Research
indicates that sleep medications are comparable in efficacy to CBT-I in the short-term
(Mitchell et al., 2012); however, CBT-I’s effect is more durable and is preferred by
patients when given a choice (Cheung et al., 2018; Mitchell et al., 2012). Generally,
medication does not influence the process and outcome of psychotherapy (Morin
et al., 2009); however, medication use is recommended to be kept consistent, rather
than contingent, in its use. Using medication at a similar time and dose supports
positive sleep self-efficacy by avoiding situations where the patient takes medication
reactively to thoughts of not being able to sleep.
In some sleep disorders, however, sleep medication is the first-line recommended
treatment, such as restless legs syndrome (Earley & Silber, 2010) and narcolepsy
(Thorpy, 2007).

Conclusion
Insomnia is a burdensome and costly condition, and CBT-I is a relatively short-term
treatment with high potential impact. Indeed, CBT-I is the gold-standard treatment
for insomnia and there is a strong empirical base supporting its efficacy. Moreover,
there is support for its mechanisms. The etiological underpinnings of ID are that
conditioned arousal, reduced sleep drive, and a dysregulated clock perpetuate
chronic insomnia, and stimulus control and SRT have effects across these factors.
SRT and sleep hygiene are the two behavioral components of CBT-I with some
support as monotherapies, albeit not as strong as combining them in a multicompo-
nent treatment. Sleep hygiene is not a recommended treatment and there is no
empirical base for its recommendation as a stand-alone treatment for insomnia.
CBT-I has been shown to be effective in children and adolescents and across several
common comorbidities. With respect to the assessment of insomnia, subjective
patient reports are the gold standard, as how patients perceive their symptoms is
what matters. Burdensome objective measures of sleep disturbance don’t necessarily
relate to the patients’ experience and the disorder is subjective.

Useful Resources

• American Academy of Sleep Medicine: www.aasm.org

• Association for Behavioral and Cognitive Therapies: www.abct.org
• Canadian Sleep Society: www.css-scs.ca
• Society for Behavioral Sleep Medicine: www.behavioralsleep.org
 Insomnia Disorder 169

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 11
Sexual Dysfunctions
Amy D. Lykins and Marta Meana

Sexuality was at the center of early psychodynamic theorizing about the etiology of
psychological conflict, but it was not until Masters and Johnson (1970) introduced sex
therapy that sexual dysfunction became the specific target of treatment. Equipped
with their model of the sexual response cycle as consisting of the distinct and
sequential stages of excitement, plateau, orgasm, and resolution, they proceeded to
develop interventions specific to the challenges therein. Kaplan (1979) later intro-
duced desire as a first motivational stage and pared the model down to three phases:
desire, arousal, and orgasm. It is this triphasic model that has been the organizing
principle behind the seven sexual dysfunctions not directly attributable to a substance
or medication in the latest version of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5-TR; American Psychiatric Association, 2022) and those that
preceded it (see Pukall, 2023 for a critique of these early conceptualizations).
A heterogeneous group of disorders with varying etiologies and gender-specific
manifestations, they are clustered together as a function of their interference with
sexual activity, responsivity, and/or pleasure, as well as associated distress with said
interference. Using the three morbidity criteria in the DSM-5 (6-month persistence,
experienced on 75–100% of sexual encounters, and causing significant distress), most
dysfunctions are relatively prevalent when assessed for their presence in the past year
(population prevalence rates range from 5.2% to 25.0%1) and can result in significant
relationship challenges.
Disorders of desire are characterized by deficient or absent sexual thoughts, fanta-
sies, and/or desire for sexual activity. In men, this problem is diagnosed as male
hypoactive sexual desire disorder (MHSDD; 5.2% prevalence rate), with low esti-
mated prevalence rates in young men that increase with age (Corona et al., 2013); in
women, low desire and arousal problems (lack of response to sexual cues and/or
absent or reduced physical sensations) are combined under the diagnostic criteria for

1
Please note that all prevalence rates have been reported as per Mitchell et al.’s (2016) population-based assessment
of sexual function problems.

175
176 Amy D. Lykins and Marta Meana

female sexual interest/arousal disorder (FSIAD), a much more commonly presenting

disorder (9.1% prevalence rate; Mitchell et al., 2013, 2016). The disorder of arousal
specific to men is erectile disorder (ED; 14.1% prevalence rate), characterized by
significant difficulty in obtaining or maintaining an erection, and/or a marked
decrease in erectile rigidity, a dysfunction with an increasing prevalence rate as
men age (Lewis et al., 2010). Disorders relating to orgasm are also gender specific.
Delayed ejaculation (DE) (5.5% prevalence rate) and female orgasmic disorder
(FOD) (11.6% prevalence rate) entail problems achieving orgasm, including reduced
intensity of orgasmic sensations. Men can also be diagnosed with premature (early)
ejaculation (PE) (11.6% prevalence rate) when orgasm occurs within one minute of
vaginal penetration (and before the person wishes it). Finally, genito-pelvic pain/
penetration disorder (GPPPD) (25.0% prevalence rate) combines the old DSM-IV
diagnoses of dyspareunia and vaginismus and encompasses a number of conditions
(e.g., vulvodynia, age-related vaginal atrophy) that can cause pain with penetration, as
well as a phobic anxiety and fear of penetration most commonly associated with
vaginismus in the past. It is a relatively common disorder currently diagnosed only in
women (Christensen et al., 2011; Pukall et al., 2016).

Etiology and Theoretical Underpinnings of Treatment

Historically, etiological factors for impaired sexual performance have swung from
psychological to physical explanations and back again, finally settling on the more
holistic biopsychosocial approach (Meana & Hall, 2023). The etiological drivers of
sexual dysfunctions are as multifaceted as their clinical presentations (e.g., Bancroft,
2009) and are generally multifactorial; all potential biological, psychological, and
relational factors should be considered as part of a comprehensive clinical assessment.
The DSM-5-TR (APA, 2022) specifies five areas of consideration for assessment, as
they are known to be associated with sexual functioning: (1) partner factors, including
comorbid partner dysfunction or physical health issues; (2) relationship factors, such
as poor communication and discrepant desire; (3) intrapersonal factors, such as poor
body image, histories of abuse, comorbid psychological problems, and high levels of
stress; (4) the client’s cultural and religious context, as it affects sexual scripts and the
value placed on sexual pleasure; and (5) common medical problems (e.g., injuries,
infections, cardiovascular diseases) that can impact sexual function.
Masters and Johnson’s groundbreaking new sex therapy approached treatment
from a cognitive-behavioral perspective and included components of psychoeduca-
tion (based on the premise that many sexual problems were the result of a lack of
sexual knowledge), along with cognitive interventions and behavioral exercises. In
positing that performance anxiety lay at the heart of sexual dysfunction, therapy
aimed to remove goal-based performance and replace it with a focus on pleasure,
using both behavioral and, to a lesser degree, cognitive techniques. Components of
 Sexual Dysfunctions 177

systematic desensitization, guided practice, and cognitive restructuring remain

important elements of treatment for sexual dysfunctions 50 years later. Growing
recognition of the relevance of physiological factors also led to the rise of sexual
medicine and the integration of pharmaceutical and physiological treatments into
therapies for sexual dysfunction. Best practice recommendations advise that these
multidisciplinary treatment approaches be implemented concurrently for optimal
outcomes (Binik & Meana, 2009).

Brief Overview of Treatments

Due to the heterogeneous nature of the disorders classified as sexual dysfunctions,
there is no “one-size-fits-all” treatment package for intervention. A woman experien-
cing pain with intercourse will be treated very differently than a man experiencing
erectile difficulties. On the other hand, it is likely that, despite radically different
etiologies to their problem, both are engaging in thoughts and behaviors that maintain
or compound the problem. It is also likely that patterns of communication between
them and their partners have become dysregulated around this specific issue, further
complicating the situation. Consequently, there are significant commonalities across
treatment packages as they target the cognitive, emotional, behavioral, and relational
dynamics that can either hinder or facilitate treatment progress.
The overall level of research support for the psychological treatment of sexual
dysfunctions is poor. Despite Masters and Johnson’s early claims of high efficacy
with brief, time-limited interventions, these results have either failed to be replicated
or have simply not been revisited with today’s more rigorous research standards (see
Fruhauf et al., 2013 for systematic review and meta-analysis). Psychological inter-
ventions for most disorders would not have met the criteria for “well established”
efficacy as defined by Chambless et al. (1998), not to mention the far more stringent
standards of the Tolin et al. (2015) criteria. Relatively few randomized control trials
(RCTs) have been conducted on psychological interventions for sexual dysfunctions,
and they are of varying quality (Fruhauf et al., 2013). As per the aforementioned
review, there is good evidence for the effectiveness of psychological interventions for
sexual desire and orgasm problems in women; however, no consistent reductions in
symptom severity for ED, PE, or vaginismus were observed in their analyses. Most of
the more recent RCTs have assessed the efficacy of treatment for GPPPD, in which
surgical (Landry et al., 2008) and physical therapy (Morin et al., 2017) interventions
continue to evidence the best outcomes.
The relative lack of high-quality RCTs for sexual dysfunctions makes it difficult
to draw conclusions on psychological treatment efficacy with any confidence. As
discussed by Meana and colleagues (2020), the reasons for this gap are likely both
practical and philosophical. Research on sex therapy interventions is notably under-
funded, particularly in the United States. The preference for a simple pill, and the
178 Amy D. Lykins and Marta Meana

financial incentive for pharmaceutical companies to develop and deliver said pill,
far outweighs any monetary motivation for outcome assessments of psychological
interventions. As a result, most of the RCTs for sexual dysfunctions have investigated
the treatment efficacy of available pharmaceutical options, leaving the efficacy of
psychotherapeutic interventions relatively uncharted.
Perhaps most importantly, a consistent and agreed-upon definition for outcome
success in sexual dysfunction intervention is evasive. Restoring “function” in some-
one with a “dysfunction” can sometimes be clear: a man with PE can now have sex for
longer than one minute, a woman previously experiencing pain during intercourse
no longer does so, or a man with ED can obtain an erection sufficiently rigid for
penetration. In other cases, despite improvements, the man may still not last as long as
he or his partner desires, or intercourse pain may not completely remit, or desire may
have increased but continues to pale in comparison to a partner’s. Where does the
treatment success line lie? A growing number of therapists and researchers are
banking on sexual satisfaction and the reduction of distress as the only truly viable
treatment outcome measures, as originally proposed by Rosen and Bachman (2008).
This may seem a capitulation to treatment indeterminacy but, arguably, increasing
sexual satisfaction can, in turn, have a powerful impact on function when it can be
restored. In cases in which it cannot, such as age-related changes that are not easily
amenable to change, finding alternate ways to achieve sexual satisfaction can be
fruitful outcome goals. Additionally, given the multifactorial nature of sexual dys-
function etiology, there are a variety of issues that could present as sexual problems
that may require techniques that do not address sexual functioning specifically,
including increasing self-esteem and body image, reducing life stressors, and address-
ing problematic relationship dynamics. If these lead to greater sexual and relationship
satisfaction even in the face of unremitting or reduced function problems, this would
be considered a “success” by many psychotherapists and clients. Ultimately, sexuality
is not about plumbing as much as it is about pleasure and human connection, both of
which happily can arise in many ways.

Credible Components of Treatments

In 2009, Binik and Meana provided a detailed table that matched the major
components of psychotherapy interventions that are implemented in the treat-
ment of sexual dysfunctions. Their goal was twofold: first, to emphasize the
many commonalities across the treatment of different dysfunctions, and second,
to demonstrate that most interventions are well within the toolkit of general
therapists who might want to join the effort to treat these highly prevalent
problems. These interventions, covered in the following section, remain the
most commonly utilized, as well as ones that have demonstrated treatment
efficacy, if not always as rigorously as would be optimal.
 Sexual Dysfunctions 179

Psychoeducation
Delivery of psychoeducation on the basic features of sexual response and skills is
typically the first step in therapy for sexual dysfunctions, though the focus of this
information is guided by the person’s presenting problems. Psychoeducation was
more prominent when sex therapy was in its early years and the public did not have
access to the vast resources that are today available from a personal computer, tablet,
or phone. However, the general public still struggles to obtain reliable sex informa-
tion, and myths about sexual performance continue to abound in media depictions and
pornography.
Normalizing desire discrepancies in couples (Herbenick et al., 2014), explaining
how women’s sexual desire may more often be responsive rather than appetitive
(Basson, 2000), and deconstructing the myth that men’s sexual desire should be
unwavering are important psychoeducation points. Communicating information on
the physiology of erectile function, as well as normative age- and health-related
declines, can help normalize erectile problems and reduce stigma (Kalogeropoulos
& Larouche, 2020). Specifically, communicating how physical (e.g., cardiovascular
diseases) and mental (e.g., depression, anxiety, stress) health conditions and relation-
ship conflict can affect erectile function may also support lifestyle changes and the
inclusion of additional mental health support.
For women with difficulties attaining orgasm, basic education on sexual anatomy
and response, as well as information about types of stimulation that are likely to lead
to orgasm, may be helpful (Carvalheira & Leal, 2013; Meana, 2012). Informing
clients that most women cannot reach orgasm with vaginal penetration alone
(Mintz, 2017) can normalize their experience and lead partners to alternate forms of
stimulation. Encouraging genital self-exploration can help women learn what they
find pleasurable, which they can then direct their partners to do (Meana, 2012). For
men with PE, simply knowing what normative intravaginal ejaculatory latency times
are can go a long way toward dispelling misconceptions about how long men should
“last.” Genital self-exploration can also be useful for women experiencing GPPPD
to identify locations of pain (Bergeron et al., 2020), and psychoeducation about the
multifactorial nature of pain – how anxiety, hypervigilance, catastrophizing, and
solicitous partner responses can serve to maintain it (Rosen & Bergeron, 2019) – is
effective, as evidenced in outcome studies (Meana & Binik, 2022).

Cognitive Restructuring/Emotional Regulation

Consistent with cognitive-behavioral approaches for many nonsexual psychological
disorders, cognitive restructuring and emotional regulation practices are commonly
employed in sexual dysfunction intervention. Theories of, and a great deal of
supporting empirical data on, the development of sexual dysfunction point to
180 Amy D. Lykins and Marta Meana

performance anxiety and/or cognitive distraction as major drivers of sexual

difficulties (Barlow, 1986; McCabe, 2005; Nobre & Pinto-Gouveia, 2008).
Understanding and targeting cognitive distortions and schemas that contribute to
performance anxiety and negative automatic and maladaptive thoughts is an import-
ant component of psychotherapy for sexual dysfunctions. Poor body image and
negative attitudes about sex (e.g., guilt and shame) have been shown to contribute to
FSIAD (Brotto et al., 2016); cognitive psychotherapeutic techniques are used to
challenge these negative thoughts and promote the development of more positive
thoughts and attitudes. ED in men can be addressed with the use of positive
visualization techniques to overcome existing anxiety (such as imagining success-
fully obtaining an erection) and addressing myths and misconceptions about
men’s virility (e.g., “real men are always ready and able to obtain an erection”)
(Kalogeropoulos & Larouche, 2020). Similarly, targeting other types of maladap-
tive thoughts and beliefs (e.g., “all men can put off orgasming as long as they want”)
and reducing high emotional reactivity has shown efficacy in treating PE (Rowland
& Cooper, 2017). Addressing cognitive distraction by working to bring attention
back to the physical pleasure experienced during sexual encounters is a common
component of sexual dysfunction interventions, including for FSIAD (Brotto, 2018;
Meana, 2012), FOD (Meana, 2012), and GPPPD (Meana et al., 2023) in women, and
ED (Rowland, 2012) and DE (Meana et al., 2023) in men.
Cognitive restructuring and emotion regulation are of particular importance in the
treatment of women who experience pain during sex. Rosen and Bergeron (2019)
proposed the Interpersonal Emotion Regulation Model of women’s sexual dysfunc-
tion, and provided a particularly in-depth exploration of how this model applies to
the multifaceted experiences of women’s genito-pelvic pain. In this model, both
proximal and distal factors are posited to influence how the couple experiences
difficulties with emotional awareness, expression, and experience, and how their
use of more adaptive (e.g., reappraisal, approach, acceptance, mindfulness, prob-
lem-solving, disclosure) or less adaptive (e.g., avoidance, suppression, catastro-
phizing, emotional outbursts) emotion regulation strategies can result in different
outcomes with respect to genito-pelvic pain and overall sexual and relationship
satisfaction. Accordingly, cognitive and emotion regulation therapy techniques may
be used to encourage positive, adaptive coping strategies, as well as to manage
relevant proximal and distal factors contributing to the development and mainten-
ance of these poor emotion regulation strategies (Bergeron et al., 2020; Rosen &
Bergeron, 2019). Given that this is a relatively new theoretical model, empirical data
are scant at this time but starting to accumulate. For example, in one recent study,
Bergeron and colleagues (2021) found that perceived partner emotional responsive-
ness was associated with greater sexual function and sexual satisfaction in women
with GPPPD.
 Sexual Dysfunctions 181

Stimulus Control/Desensitization
Many of the behavioral techniques used to complement the cognitive and emotional
components of therapy for sexual dysfunctions comprise different versions of stimu-
lus control or desensitization. Some methods have general applicability, whereas
others have been designed for specific disorders.
Sensate focus exercises are generally considered relevant to the treatment of all
sexual dysfunctions. Sensate focus typically involves a temporary ban on intercourse
followed by a graduated series of exercises moving from nongenital sensual massage
to sensual genital touching, with intercourse only being reintroduced after these
earlier sessions have been completed. This process aims to remove any existing
goal-oriented performance anxiety and cognitive distraction, and to allow space for
focusing on pleasurable sensations. Recent reviews have supported the efficacy of
sensate focus exercises in treating sexual problems, though it should be noted
that most of these studies have combined sensate focus with other intervention
methods (e.g., cognitive-behavioral therapy, mindfulness) (Avery-Clark et al.,
2019; Linschoten et al., 2016).
Directed masturbation is often recommended for both male and female orgasm
disorders, as well as ED. Following psychoeducation and genital exploration, treat-
ment success for directed masturbation for women with lifelong FOD ranges from
60–90% (Laan et al., 2013). When highly prescribed and/or unusual methods of
masturbation are considered to be contributing to DE in men, it is recommended
that men work to shape their masturbation patterns to more closely approximate the
speed and friction provided by intercourse (Perelman, 2004). Kalogeropoulos and
Larouche (2020) also recommend directed masturbation to be used in the treatment
of ED by bringing more awareness to one’s sexual response and helping to build
confidence and perceptions of control.
When GPPPD is related to penetration anxiety, the Fear-Avoidance Model has
been useful in providing a “map” for understanding potential etiological and main-
tenance factors that can be targeted in treatment (ter Kuile et al., 2010). Briefly, this
model proposes that negative beliefs about or experiences with vaginal penetration
predispose a woman toward pain catastrophizing, resulting in fear, hypervigilance,
and, ultimately, avoidance. Research has shown that when penetration is attempted,
penetration-related fear and associated pelvic floor tension can be such that penetra-
tion either cannot occur or is experienced as painful (thus reinforcing the fear and
avoidance) (Lahaie et al., 2015; Reissing et al., 2004). Accordingly, exposure-based
interventions have been trialed and found to be effective (ter Kuile et al., 2013). These
exposure exercises typically involve gradual exposure to increasingly larger sized
dilators (or fingers) used for vaginal penetration (ter Kuile & Reissing, 2020).
Finally, several techniques have been developed specifically for the treatment
of PE; these include the “squeeze” and the “stop-start” techniques. The squeeze
182 Amy D. Lykins and Marta Meana

technique involves the man indicating to his partner when he feels ejaculation is
imminent, at which point sexual stimulation stops and the partner applies pressure
to the glans until arousal lessens. The stop-start technique is performed as described
above; however, the couple simply pauses sexual stimulation. The goal of these
techniques is to help the client become more aware of different levels of excitement
so that he can attain better control over ejaculation (Althof, 2020). Though later
efficacy assessments have not reached the levels of success reported by Masters and
Johnson, these techniques continue to be used in the treatment of PE (Meana & Hall,
2023).

Behavioral, Situational, and Contextual Modifications

Important components of behavioral, situational, and contextual modifications
are regularly utilized in the treatment of sexual dysfunctions. In women with
FSIAD and men with MHSDD, this may involve a greater consideration and
modification of contextual conditions (e.g., timing, environment) to ensure that
they facilitate desire and arousal. Women with FOD may be asked to role-play
losing control to lessen pre-existing anxiety associated with orgasm (Laan et al.,
2013). Men with DE may be asked to discontinue masturbating altogether
(Meana et al., 2023), and men with ED may be asked to address lifestyle factors
that contribute to erectile problems (e.g., lose weight, stop smoking) (Harte &
Meston, 2013; Silva et al., 2017). Assessing and modifying restricted sexual
scripts and behavioral repertoires is worth considering for all sexual problems.

Mindfulness
More recently, third-wave therapeutic techniques have been trialed in the treat-
ment of some female sexual dysfunctions, with promising results. According to
Brotto and Heiman (2007), mindfulness-based interventions aim to promote and
nurture active, nonjudgmental, and compassionate awareness of the body and its
sensations, resembling some aspects of older sensate focus techniques in com-
bination with more recently developed mindfulness intervention techniques. This
body of literature is in the early stages, but three randomized controlled studies
have shown success in increasing sexual desire, arousal, and relationship satis-
faction, and decreasing sexual distress in women with FSIAD (Brotto et al.,
2021); improving sexual function and satisfaction, and reducing sexual distress
in women with FOD (Adam et al., 2020); and reducing pain in women with
GPPPD (Brotto et al., 2019), indicating that mindfulness may be a useful
addition to the sex therapy toolkit.
 Sexual Dysfunctions 183

Relationship Skills-Building
Most people seeking sex therapy are in some type of relationship, and difficulties
therein can serve as etiological factors for sexual dysfunctions (and vice versa)
(McCabe & Cobain, 1998; Velten & Margraf, 2017). As such, relationship skills-
building exercises are common components of psychotherapeutic interventions for
sexual dysfunction. Therapy should address any obvious discord present in the
relationship, which may include hostility, resentment, and relationship insecurity
(Perelman & Rowland, 2006; Rowland & Cooper, 2017). Couples may need to
learn how to navigate desire discrepancies without increasing hostility and conflict
(Meana, 2012), highlighting the importance of communication training. Issues related
to communication become particularly relevant when managing pain during inter-
course, as interaction patterns may develop that are, ironically, pain-reinforcing
(Meana et al., 2023). Partner responses to pain can vary from solicitous (e.g., atten-
tion, sympathy), to negative (e.g., hostility, frustration), to facilitative (e.g., affection
and adaptive coping); research has indicated that facilitative responses are associated
with lower reports of genito-pelvic pain, and greater sexual and relationship satisfac-
tion (Rosen & Bergeron, 2019).

Other Variables Influencing Treatment

Assessment and Diagnosis
As with any psychological disorder, it is important to conduct a comprehensive
clinical assessment prior to the commencement of treatment. This is especially salient
in the case of sexual dysfunctions, given their generally multifactorial etiologies.
A detailed case conceptualization – comprising predisposing, precipitating, perpetu-
ating, and protective factors from a biopsychosocial perspective – will help to provide
a holistic understanding of how the sexual problem started, what factors are involved
in the maintenance cycle, and strengths to draw upon in treatment. Ideally, this
assessment is conducted with both members of a couple if the presenting client is
partnered. Notable rule-outs include medical conditions that have caused the dysfunc-
tion (APA, 2022); a physician’s assessment may assist with eliminating these poten-
tial explanations. Although even medically induced sexual dysfunctions often have
psychological components, psychotherapy alone in these cases is likely inappropriate.
Several standardized and freely available sexual dysfunction screening questionnaires
exist that may be useful in clinical assessment, though they should never be fully
relied upon for diagnosis. The Female Sexual Function Inventory (FSFI; Rosen et al.,
2000) is a useful measure for women, and the International Index of Erectile Function
(IIEF; Rosen et al., 1997) is a valid screener for male sexual dysfunctions (not just
erectile dysfunction, despite its title). If indicated, daily diaries may be used to record
the frequency of sexual activity and associated experiences. Additionally, in the case
184 Amy D. Lykins and Marta Meana

Box 11.1 Comprehensive Sex Education for Youth

A number of different methods for youth sex education have been developed over the
years, which typically vary by different definitions, goals, and philosophies (Goldfarb &
Lieberman, 2021). Large review studies have concluded that prevention programs,
such as abstinence-only education, largely do not appear to reduce unprotected sexual
activity, youth pregnancy rates, or rates of sexually transmitted infections (Chin et al.,
2012), and may even contribute to higher rates of teen pregnancy (Stanger-Hall & Hall,
2011).
Because abstinence-only programs have proved to be only marginally more
effective than no education at all, and not especially effective even in their intended
aims (e.g., Hall et al., 2016), sex educators are more likely to promote the use of
comprehensive sex education programs. This approach involves education on “the
sexual knowledge, beliefs, attitudes, values, and behaviors of individuals. Its various
dimensions involve the anatomy, physiology, and biochemistry of the sexual response
system; identity, orientation, roles, and personality; and thoughts, feelings, and
relationships” (SIECUS, 2018, para 1). A review by Goldfarb and Lieberman (2021)
concludes that there is “substantial evidence” supporting comprehensive sex education
that begins in primary school and is scaffolded in a developmentally appropriate
manner across K–12 educational programs. In addition to reducing rates of teen
pregnancy over no sex education, which abstinence-only education does not do
(Kohler et al., 2008), the more positive and rights-based comprehensive sex education
programs have been found to lower homophobia and reduce homophobic bullying;
expand a student’s understanding of gender and gender norms; promote the
recognition of gender equity, rights, and social justice; improve knowledge and
attitudes about, and reporting of, both dating and intimate partner violence; decrease
intimate violent behavior and victimization; promote healthy relationships by
increasing knowledge, attitudes, and communication skills in relationships; and
contribute to child sex abuse prevention (Goldfarb & Lieberman, 2021). In summary, it
appears that the best prevention of negative outcomes in teen sexuality and
relationships is knowledge rather than prohibition.

of ED, sexual psychophysiological assessment (i.e., Penile Doppler ultrasound) may

be indicated, along with a referral to a urologist.
To ensure that sexual symptoms are not transient and are simply reflective of
normal fluctuations in sexual functioning, the diagnosis of sexual dysfunction (other
than substance/medication-induced sexual dysfunction) requires that the symptoms
have persisted for at least six months. Three types of diagnostic specifiers must also be
identified in diagnosis. A lifelong problem has been present from the beginning of
a person’s sexual experiences, whereas acquired problems begin after a period of
normal sexual functioning. Generalized sexual problems are not limited to certain
types of stimulation, situations, or partners, whereas situational problems are. Lastly,
 Sexual Dysfunctions 185

the severity of the client’s distress about the presenting problem(s) must be rated as
mild, moderate, or severe. Distress is probably the most relevant of the diagnostic
criteria; if distress is not present, neither a diagnosis nor treatment is indicated.
Other diagnostic issues of note include the shift in disorder definitions and
diagnostic criteria across different versions of the DSM. In moving from the
fourth to the fifth edition, the diagnostic criteria for women, in particular,
underwent significant revision. As mentioned, previous diagnoses of hypoactive
sexual desire disorder and female sexual arousal disorder were collapsed into one
diagnosis of FSIAD. Similarly, previous diagnoses of dyspareunia and vagin-
ismus were collapsed into a diagnosis of GPPPD. Thus, much of the research
prior to 2013 may have assessed components of the current diagnoses, but how
well they address treatment outcome for the currently defined disorders requires
further investigation.

Comorbidity
Given how important satisfying sexual relationships are to overall relationship
satisfaction, it should come as no surprise that sexual dysfunctions often present
comorbid with other psychological, sexual, and medical difficulties. Perhaps most
commonly, sexual dysfunctions present as comorbid with other sexual dysfunctions
or with partner sexual dysfunction (Mitchell et al., 2016; Nobre et al., 2006).
Persistent desire and orgasm difficulties are commonly comorbid in both men
(both premature and delayed ejaculation) and women (Mitchell et al., 2016). Low
desire and deficient arousal can also exacerbate intercourse pain in women with
GPPPD, as these conditions can result in reduced vaginal lubrication, thereby
increasing the potential for pain. A variety of medical problems (e.g., cardiovascular
diseases, diabetes) and mood disorders (e.g., depression, anxiety) also frequently
present along with various sexual problems (Laurent & Simons, 2009; Polland et al.,
2018; van Lankveld & Grotjohann, 2000). Comorbidity studies are generally cor-
relational and cannot directly address causality but, in the case of mental health
problems, it is reasonable to posit that their relationship with sexual dysfunction is
bidirectional.

Demographics
Critically, the DSM-5-TR (APA, 2022) notes that gender-diverse people may not fit
neatly into the binary gender constructs that currently separate some sexual dys-
function diagnoses. Unless specifically defined by anatomy (e.g., ED, PE, DE,
GPPPD), diagnoses can be applied to gender-diverse individuals as judged to be
clinically relevant. Also worth noting are the normative age-related declines in
sexual functioning which can contribute to desire, arousal, and orgasm difficulties;
186 Amy D. Lykins and Marta Meana

a comprehensive diagnostic assessment will help delineate between the conse-

quences of normative aging processes and clinical disorders. Lastly, the great
majority of the research conducted on sexual function has been conducted on
members of so-called “WEIRD” (i.e., Western, educated, industrialized, rich, and
democratic) societies, which represent only 12% of the world’s population (Henrich
et al., 2010). As Hall and Graham (2020) have noted, culture exacts a significant
influence on sexual behaviors, norms, and expectations. Studies investigating the
prevalence and experiences of sexual dysfunctions cross-culturally have found
a great deal of variation in what people report as problematic. Furthermore, given
that much of sex therapy was developed in these WEIRD societies, their utility in
more diverse communities is currently unknown (Hall & Graham, 2020). This gap
in knowledge requires targeted investigation to ensure that we are conducting sex
research with diverse populations and delivering sex therapy interventions in
a humble and culturally responsive manner.

Medication
Given the biopsychosocial nature of sexual dysfunctions, multiple treatment options
may be required to target different aspects of these experiences. Concurrent multidis-
ciplinary treatment modalities have shown efficacy in intervention for several sexual
dysfunctions, although more research on this team approach is needed (Binik &
Meana, 2009). While multimethod treatments delivered by a coordinated team of
specialists is not a novel idea, the power in these interventions derives from their
concurrent (rather than serial) implementation, so that treatment gains in one area can
reinforce those in others.
Outcome research has revealed good efficacy of concurrent psychotherapeutic
and medical interventions. A combined psychotherapy and medical approach for
treating PE – typically involving medications known to delay orgasm (e.g.,
selective serotonin reuptake inhibitors) or topical agents that reduce penile
sensitivity – have shown superior efficacy to either method alone (Althof,
2020). Likewise, the recommended approach for the treatment of ED involves
psychotherapy delivered with a PDE-5 inhibitor (e.g., sildenafil), as in one study,
while both PDE-5 inhibitor alone and PDE-5 inhibitor plus cognitive-behavioral
sex therapy showed efficacy in improving erectile function, only the combined
treatment also resulted in improved couple sexual satisfaction and female sexual
function (Boddi et al., 2015). Recommended treatment protocols for women with
GPPPD involve psychotherapy, pelvic floor physical therapy, and, if indicated,
vestibulectomy (i.e., excision of the posterior hymen and painful mucosa in the
posterior and anterior vestibule) (Landry et al., 2008; Meana & Binik, 2022;
Morin et al., 2017). To date, research has not examined the extent to which
somatic treatments help or hinder psychological therapy for GPPPD.
 Sexual Dysfunctions 187

Conclusion
Sex therapy continues to thrive despite the paucity of sound empirical studies
attesting to its effectiveness. The treatment components covered here represent
the core of clinical practice, some with direct empirical support from studies on
participants with sexual dysfunction and others with empirical support from the
larger body of cognitive-behavioral therapy applied to any number of disorders.
In the absence of funding for treatment outcome studies, sex therapists continue
to respond to their clients’ appeals for help with theoretically sound practices
that represent reasonable choices. The Masters and Johnson promise of highly
effective short treatments did not pan out quite as simply as they claimed, but
they drew much-needed attention to sexual concerns and laid a foundation that
has persisted to a large extent. In order to confidently assert sex therapy’s
efficacy for different dysfunctions, we would have to witness a dramatic increase
in RCTs. However, that is not to say that current practice is not effective; we
simply do not know the extent to which it is effective in the case of most sexual
dysfunctions. On the other hand, the core elements of psychoeducation, cogni-
tive restructuring/emotional regulation, stimulus control, behavioral/contextual/
situational modification, mindfulness, and relationship skill building are hardly
esoteric. They are at the heart of current cognitive-behavioral therapy practice
and they boast empirical support in the treatment of a large number of psycho-
logical challenges. Their importation into the sex therapy enterprise seems wise
as we await further empirical validation.
The undeniably physical component of the sexual response also challenges sex
therapists to collaborate with physical therapists, gynecologists, and urologists to
build treatment teams that can simultaneously target all reasonably identified
etiological factors. This will no doubt complicate the treatment outcome research
effort, but there is little sense in testing only one component of what in many
cases will be a multidisciplinary treatment. An additional challenge is the defin-
ition of treatment success across dysfunctions and the roles of sexual satisfaction
and distress reduction versus improvements in actual function. Looking ahead,
treatment for sexual dysfunctions will also have to grapple with socioeconomic
and cultural considerations, not to mention the more complex sexual and gender
identity landscape that we now know to be more characteristic of our clients than
we previously appreciated. Thus, clinical practice continues in the face of these
challenges, and in light of these opportunities to broaden the horizon of treatment
for sexual dysfunctions. The scientific enterprise in support of sex therapy is likely
to continue lagging behind the highly needed practice of sex therapy. We cannot
wait for science to catch up, as clients’ distress is in the here and now. We can,
however, continue to adhere to evidence-based treatments that should reasonably
transfer to the aid of sexual challenges.
188 Amy D. Lykins and Marta Meana

Useful Resources

• Brotto, L. A., & Nagoski, E. (2018). Better sex through mindfulness: How women can
cultivate desire. Greystone Books.
• Goldstein, A., Pukall, C. F., & Goldstein I. (2020). Female sexual pain disorders evaluation
and management (2nd ed.). Wiley-Blackwell.
• Hall, K. S. K., & Binik, Y. M. (2020). Principles and practice of sex therapy (6th ed.).
Guilford Press.
• McCarthy, B. W., & McCarthy, E. J. (2021). Contemporary male sexuality: Confronting
myths and promoting change. Routledge.
• Meana, M. (2012). Sexual dysfunction in women. Hogrefe Publishing.
• Perel, E. (2007). Mating in captivity: Unlocking erotic intelligence). Harper.
• Rowland, D. (2012). Sexual dysfunction in men. Hogrefe Publishing.

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 12
Substance Use Disorders
Victoria E. Stead, Andrew B. Lumb, Jennifer Brasch, and James MacKillop

Substance use disorders (SUDs) are among the most common psychiatric conditions
and are major global causes of morbidity and mortality. Diagnostically, SUDs are
defined differently in the Diagnostic and Statistical Manual, 5th Edition, Text
Revision (DSM-5-TR) and the International Statistical Classification of Diseases
and Related Health Problems, 11th revision (ICD-11) (APA, 2013; WHO, 2019).
Both nosological systems include symptoms related to loss of control over substance
use and substance use taking over other activities, resulting in life-long health
problems, tolerance, and physiological withdrawal effects (APA, 2013; WHO,
2019). The DSM-5-TR uses a single continuous polythetic diagnosis – substance
use disorder – with three levels of severity (mild, moderate, and severe), whereas
ICD-11 has two diagnoses – harmful pattern of use and substance dependence – with
the former being less severe. These diagnoses clinically operationalize the colloquial
term “addiction,” although the construct of addiction generally connotes more severe
manifestations (i.e., severe substance use disorder, substance dependence) (McLellan
et al., 2022).

Etiology and Theoretical Underpinnings of Treatment

Contemporary theories of SUDs emphasize a highly multifactorial etiology and
an integrative biopsychosocial approach (MacKillop & Ray, 2018). The primary
focus here is on psychological determinants; however, there is a recognition of
important biological factors such as genetic liability (Goldman et al., 2006) and
neuroadaptive changes based on persistent exposure to the drug’s pharmaco-
logical actions (Koob, 2006). Similarly, social and sociocultural factors, such as
drug policy (e.g., taxation, minimum age of legal access, legal status) and
presence of prevention programming, are also established as affecting SUD
risk (MacKillop et al., 2022).
From a psychological standpoint, these biological and sociocultural processes
are integrated into a perspective that emphasizes behavioral and cognitive factors
193
194 Stead, Lumb, Brasch, and MacKillop

that underlie SUDs. A major theme in contemporary psychological theories of

SUDs is the application of learning theory, which posits that excessive and
problematic substance use reflects a form of maladaptive learning. The earliest
perspective, and one that is still influential, is an operant (instrumental) learning
perspective (Bigelow, 2001). Specifically, this approach theorizes SUDs to be
maladaptive instrumental learning that is governed by the positively and nega-
tively reinforcing psychoactive effects of the drug that have become excessively
dominant and often displace more salutary nondrug alternative reinforcers. This
approach is supported by an extensive evidence base, from human laboratory
studies demonstrating drug self-administration conforming to operant predictions
to observational and clinical studies implicating overvaluation of immediate
reinforcement, persistently high drug reinforcing value, and a dearth of alternative
reinforcers (Acuff et al., 2019; González-Roz et al., 2019; MacKillop et al., 2011;
Martínez-Loredo et al., 2021). The most recent incarnation of a reinforcement-
based formulation is referred to as the reinforcer pathology approach, which
integrates these psychological principles with concepts and methods from micro-
economics (Bickel et al., 2014; Mackillop, 2016).
A second learning-based account of addiction emphasizes social learning theory
(Monti & O’Leary, 1999; Bandura, 1977; Monti, 2002) and emerged as an application
of the broader cognitive-behavioral approach in clinical psychology. Rather than
emphasizing reinforcing value per se, this perspective theorizes that substance use
is maintained by skills deficits (e.g., difficulty resisting social pressures to use) and
maladaptive cognitions (e.g., equating a single lapse with full relapse). A social
learning account emphasizes that individuals with SUDs lack the skills to cope with
affectively negative experiences (e.g., stress, sadness, cravings, withdrawal symp-
toms), as well as other situations associated with substance use (e.g., being around
others using substances). Substance use becomes a prepotent maladaptive coping
strategy for managing diverse antecedents.
A final important element in a contemporary psychological approach to SUDs
pertains to motivation for recovery. In contrast to lay notions that individuals with
SUDs are uniformly in “denial,” there is extensive evidence that many individuals
are indeed motivated or actively trying to change. Moreover, motivation for change,
for individuals with SUDs and other psychiatric conditions, is increasingly under-
stood to be fluid (state-like versus trait-like), and existing on a spectrum, from
resistance to high desire for and action toward change. This is the transtheoretical
stages of change model that emphasizes a sequential progression from pre-
contemplation, reflecting minimal motivation, to action and maintenance, reflecting
meaningful efforts toward behavior change (DiClemente et al., 2004; Prochaska &
DiClemente, 1983, 1992). As important has been the insight that, rather than
needing to “break through” denial, empathy and a client-centered approach is
critical for change (Miller & Rose, 2009). This is a brief overview of contemporary
 Substance Use Disorders 195

psychological theories of SUDs, and these learning and motivational perspectives

provide a theoretical foundation for science-based components of treatment that are
reviewed below.

Brief Overview of Treatments

A number of psychological treatments for SUDs have robust scientific support.
First, cognitive-behavioral therapy (CBT) for SUDs is considered a first-line psy-
chotherapy and is an extension of the broader “second wave” cognitive-behavioral
movement in psychotherapy (Beck et al., 1993; Ray et al., 2020). Second, motiv-
ational interviewing and motivational enhancement therapy (MET) are client-
centered treatment approaches that aim to strengthen a client’s intrinsic motivation
for and commitment to healthier behavior change through exploring and resolving
ambivalence (Miller & Rollnick, 2012). Using the Chambless criteria for empiric-
ally supported treatments (Chambless & Hollon, 1998), the Society of Clinical
Psychology (n.d.) designated motivational interviewing, MET, and MET + CBT
as all being well-established treatments for SUDs in general. Third and fourth are
two forms of reinforcement-based treatment – contingency management and the
community reinforcement approach – both of which have been extensively sup-
ported. Contingency management is a behavioral treatment using direct incentives
to reinforce treatment engagement and behavior change, whereas the Community
Reinforcement Approach (CRA) is a comprehensive psychosocial intervention to
develop alternative competing reinforcers that decrease the reinforcing values of
substance use (for a review, see Pfund et al., 2022).
To date, a few treatments have been evaluated using the Tolin criteria for
empirically supported treatments (Tolin et al., 2015). First, a recent systematic
review evaluated five meta-analyses of CBT for SUDs and endorsed a strong
recommendation (but not yet a very strong recommendation) for CBT for SUDs
based on the outcomes, quality of evidence, and other important contextual
considerations (e.g., efficacy in diverse populations, cost, flexibility of delivery,
etc.) (Boness et al., 2023). Of note, CBT was determined to be most effective at
short-term (1–6 months) versus long-term (8+ months) follow-up (Boness et al.,
2023). Second, a recent systematic review and meta-analysis evaluated five meta-
analyses of contingency management (Pfund et al., 2022). Two were rated as
“moderate quality,” with the other three rated as “low–critically low quality.” In
these studies, contingency management was evaluated against active treatment,
placebo, treatment as usual, and inactive/no treatment, with the primary outcome
being abstinence. Contingency management was given a strong recommendation
and deemed most effective (i.e., “moderate quality”) when compared with all
control groups on measures of abstinence and follow-up abstinence (Pfund et al.,
2022). See also page 402 of this book’s Postscript.
196 Stead, Lumb, Brasch, and MacKillop

Box 12.1 Mutual Support Organizations

Traditional mutual support organizations (MSOs), like Alcoholic Anonymous (AA) or

Narcotics Anonymous (NA), use a twelve-step program that comprises regular group
meetings, fellowship from others, and a spiritual model toward recovery. Though
ubiquitous in the treatment community, MSOs are grassroots self-help organizations
rather than empirically supported interventions per se and, until relatively recently,
research on the utility of these programs was methodologically poor (Kelly et al., 2017;
Sparks, 2014). More recent research has shown AA participation, and treatments
designed to simulate participation in AA (i.e., Twelve-Step Facilitation [TSF]), to be
beneficial (Kelly et al., 2020). Indeed, even when compared to theoretically driven,
empirically supported interventions, TSF tends to produce as-good or better outcomes,
particularly for sustained abstinence and remission, in randomized controlled
trials (Kelly et al., 2020). Although how MSOs help patients is not fully understood,
similar mechanisms to empirically supported treatments and long-term social support
are hypothesized to drive positive outcomes for those who deeply engage with these
programs (Connery et al., 2020; Kelly et al., 2021). Importantly, MSOs, and TSFs in
particular, are not necessarily a good fit for all patients, as some do not resonate with the
emphasis on spirituality, the twelve-step tenets, or abstinence as the principal definition
of successful recovery. Finally, a relatively novel MSO is Self-Management and Recovery
Training (SMART), which includes elements of motivational interviewing and CBT in
a mutual support group format has been found to provide positive effects (Beck et al.,
2017; Connery et al., 2020).

Credible Components of Treatments

Skills Training
Promoting the development of new skills to reduce substance use is a cornerstone of
CBT for SUDs. CBT approaches emphasize instrumental and social learning theory,
meaning this approach targets an individual’s learning history and environment in
determining behavior (Liese & Beck, 2022). Within the CBT model for SUDs,
substance use is typically understood as being a maladaptive coping strategy that
individuals use in response to internal and external triggers (e.g., interpersonal
conflict, boredom, withdrawal symptoms, environmental cues). Broadly speaking,
CBT for SUDs targets cognitive, affective, and environmental risk factors for sub-
stance use and incorporates training in coping skills to ultimately help individuals
reduce the harms associated with their use and/or maintain abstinence. The overall
goal of treatment is to help individuals learn skills to address the factors that lead to
their substance use (i.e., antecedents of their use). Ongoing case conceptualization of
proximal and distal factors associated with clients’ use is considered an essential
aspect of CBT for SUDs. This is to help individuals ultimately be better able to
anticipate and thus better able to cope with identified factors that might make them
 Substance Use Disorders 197

more vulnerable to using. Concurrently, individuals also learn how and when to
employ different, more adaptive, coping strategies (e.g., refusal skills, distract and
delay) (Daley & Douaihy, 2019; Marlatt & Donovan, 2005). As individuals expand
their repertoire of coping strategies, the aim is for them to become less reliant on using
substances as a primary means to cope.
In terms of empirical support, an early meta-analysis by Magill and Ray (2009)
examined the efficacy of CBT across studies targeting substance use, finding that 58%
of patients who received CBT showed significantly better outcomes (i.e., performed better
than median score for the comparison group, ranging from minimal treatment to non-CBT
treatment-as-usual). Of note, the benefit of CBT was largest in studies on cannabis use,
and female patients showed better outcomes than males. An updated meta-analysis by
Magill et al. (2019) examined CBT across SUDs in a larger group of more heterogeneous
studies, albeit finding a more modest effect size of benefit relative to minimal treatment.
When examining the efficacy of CBT compared to other therapies (e.g., motivational
interviewing and contingency management), the outcomes were equivalent. Taken
together, CBT appears to be efficacious in general, and similar in benefits to other
evidence-based strategies (Magill et al., 2019, 2020; McHugh et al., 2010).
Though there is general evidence supporting the use of CBT for SUDs, not all
CBT-based approaches have been rigorously tested across all substances to date (Liese
& Beck, 2022; Magill et al., 2019). Indeed, a challenge within the current literature is the
substantial heterogeneity across studies relating to the substances targeted, co-occurring
clinical presentations, length of intervention, format of interventions (individual versus
group), comparison groups/treatments, combination of treatment modalities (e.g., add-
ition of pharmacotherapy and/or other evidence-based modalities), methods employed,
and mechanisms of treatment change assessed (Magill et al., 2019, 2020; Ray et al.,
2020). As a result, rather than being a singular set of elements, CBT for SUDs can be
thought of as a genus comprising a number of species.
The earliest and most widely implemented CBT-based approaches include relapse
prevention (Marlatt & Gordon, 1985), which emphasizes the identification and
prevention of high-risk situations, and coping/communication skills training (e.g.,
substance refusal skills, developing social nonsubstance supports, etc.) (Monti &
O’Leary, 1999; Monti et al., 2001), which focuses on addressing deficits that are
commonly present among individuals with SUDs. The CBT approach has also been
adapted into behavioral couples therapy (McCrady et al., 2009), which has been
supported for both short- and long-term outcomes (Klostermann et al., 2011;
McCrady et al., 2009; Powers et al., 2008). Other important outcomes for behavioral
couple therapy (BCT) include increased adjustment for children of parents with
alcohol use disorder (AUD) receiving BCT (Kelley & Fals-Stewart, 2002; Lam, Fals-
Stewart, & Kelley, 2008). Additionally, two preliminary studies supported BCT for
treating dual-AUD couples (McCrady et al., 2009; Rotunda et al., 2008),
a challenging subpopulation.
198 Stead, Lumb, Brasch, and MacKillop

In addition to the coping skills noted here, a more recently developed component of
CBT for SUDs is mindfulness training in the form of mindfulness-based relapse
prevention (MBRP). This approach combines mindfulness practices (i.e., purposefully
paying attention to the present moment without judgment; Kabat-Zinn, 1994) and
conventional relapse-prevention skills training (Bowen et al., 2014). The main goals
of MBRP are to promote attentional awareness of internal and external cues related to
substance use, thus reducing automatic engagement of substance use, but also, critic-
ally, to enhance tolerance for uncomfortable and painful emotional states rather than
relief via substance use (Korecki et al., 2020). Initial evidence for MBRP supports its
efficacy in significantly lowering levels of substance use and cravings, while increasing
acceptance and awareness of the present moment, and self regulation and emotion
regulation (Li et al., 2017), though results have been mixed (Zgierska et al., 2019).
A gap in knowledge for CBT for SUDs pertains to evidence supporting individual
specific skills training as opposed to the omnibus packages that are typically
delivered. In other words, there is limited evidence for each of the specific compo-
nents of treatment. Dismantling studies and studies specifically investigating individ-
ual skills as mechanisms of behavior change are a priority for determining the value of
individual domains and potentially optimizing outcomes.

Motivational Enhancement
Enhancing and sustaining motivation for changing substance use is the superordinate
goal of motivational interviewing. This is based on the contemporary understanding that
motivation for change is malleable and fluctuating in SUDs. In other words, patients
shouldn’t be categorized as “motivated” or “unmotivated” because motivation is
a dynamic, continuous psychological process, not a dichotomous one. Originally,
motivational interviewing comprised four core principles – expressing empathy, devel-
oping discrepancy, supporting self-efficacy, and rolling with resistance (Miller &
Rollnick, 2002) – but it has evolved to focus on motivational interviewing spirit and
specific fundamental processes (Miller & Rollnick, 2012). The spirit is defined as
a therapeutic alliance that is a collaborative partnership fostering an autonomy-
supportive, nonjudgmental, and compassionate atmosphere that affirms clients’ values
and strengths (Miller & Rollnick, 2012). The fundamental processes include: (1)
engaging, where a working relationship with clients is established by building trust
through accurately understanding their perspective; (2) focusing, where therapist and
client come to a shared idea about the main focus in session, akin to agenda setting; (3)
evoking, where therapists help clients explore their own reasons for change (“change
talk”) and amplify the strength and frequency of change talk; and (4) planning, where
therapists help clients consider a menu of options and collaboratively plan how they will
go about change. These fundamentals are intended to be initially sequential, but more
broadly recursive, with the focus shifting as priorities warrant during treatment.
 Substance Use Disorders 199

In terms of empirical support, a review by Lundahl and Burke (2009) revealed that
motivational interviewing produced 10–20% greater improvement on outcomes com-
pared to no treatment and that motivational interviewing was generally equal to other
active treatments for alcohol, cannabis, tobacco, and use of other illicit drugs
(cocaine, heroin). More recently, a review (DiClemente et al., 2017) of 34 review
articles revealed the strongest evidence for motivational interviewing and brief
motivational interviewing interventions (e.g., one 15-minute session, one hour-long
session, to four or more one-hour long sessions) on substance use outcomes and
treatment engagement in the areas of alcohol, tobacco, and cannabis use. For these
substances, motivational interviewing was more effective than no treatment and equal
to other active treatments.
In terms of individual processes, an extensive literature has investigated therapist
and client behaviors, as these are essential to understand the underlying mechanisms
and efficacy of motivational interviewing. Generally, it is proposed that behavior
consistent with motivational interviewing will elicit and reinforce client language in
favor of change, which will result in improved outcomes (Miller, 1983; Miller &
Rollnick, 2012). Findings reveal that therapist behaviors that are consistent with
motivational interviewing increase client change talk (Apodaca & Longabaugh,
2009; Romano & Peters, 2016), increase realization of the discrepancy between values
and behaviors, and decrease resistance (Apodaca & Longabaugh, 2009). Increased
change talk is, in turn, related to reductions in substance use at follow-up (Magill et al.,
2018, 2019; Romano & Peters, 2016). Interestingly, behaviors consistent with motiv-
ational interviewing increase both change and sustain talk (Magill et al., 2018).
Clinically, this may not be surprising, as the process of resolving ambivalence may
at first simultaneously heighten change and sustain talk, followed by resolution,
wherein clients strengthen their language in favor of change. A systematic review by
Romano and Peters (2016) revealed that a higher ratio of therapist reflections to
questions and more use of affirmations predicted positive outcomes most consistently.
Therapist empathy and spirit of motivational interviewing have also been shown to
increase client change and sustain talk, increase therapist behaviors that are consistent
with motivational interviewing, and decrease behaviors that are inconsistent with
motivational interviewing (Pace et al., 2017). Conversely, therapist behaviors that
are inconsistent with motivational interviewing lead to more sustain talk and worse
outcomes (Apodaca & Longabaugh, 2009; Magill et al., 2018; Pace et al., 2017).

Access to Nondrug Alternative Reinforcement

Often, social learning and operant learning perspectives are broadly classed together
as CBT treatment of SUDs because of the common emphasis on a person’s learning
history. However, there is a distinction because traditional CBT (as discussed
earlier) emphasizes intraindividual factors (e.g., coping skills), whereas operant
200 Stead, Lumb, Brasch, and MacKillop

(reinforcement-based) treatments emphasize modifying extraindividual (environ-

mental) factors, specifically in the form of increasing nondrug alternative reinforce-
ment. The two operant treatment approaches that use this perspective are the
community reinforcement approach (CRA; Hunt & Azrin, 1973), which is
a comprehensive psychosocial intervention that works with the client to develop
alternative competing sources of reinforcement that are mutually exclusive with
substance use, and contingency management (Stitzer & Petry, 2006), a strategy that
directly reinforces treatment-related behaviors, such as abstinence or treatment
attendance, using direct incentives. These approaches are premised on the founda-
tional behavioral evidence that addictive substances are powerful positive and
negative reinforcers, and, for individuals with SUDs, a substance’s reinforcing
value becomes persistently elevated, disrupting other meaningful activities and
creating a vicious cycle in which substance use becomes one of the few reinforcing
behaviors available in a person’s life.
There is considerable empirical support for the efficacy of both CRA and contin-
gency management. Importantly, CRA has been adapted into an intervention for
families of individuals with SUDs – community reinforcement approach family
training (CRAFT) – which has also been found to be efficacious (Dutcher et al.,
2009; Kirby et al., 1999; Meyers et al., 2002; Miller et al., 1999; Sisson & Azrin,
1986). There is a similarly strong empirical literature supporting the efficacy of
contingency management (Dougherty et al., 2014; Higgins et al., 2000;
Ledgerwood et al., 2014; McCaul et al., 1984; Petry et al., 2000, 2013). An early meta-
analysis of more than 40 randomized controlled trials supported the efficacy of this
treatment (Prendergast et al., 2006), and subsequent ones have been similarly sup-
portive (Bentzley et al., 2021; Bolívar et al., 2021; Brown & DeFulio, 2020; Notley
et al., 2019; Winters et al., 2021). Furthermore, contingency management has been
shown to be beneficial in complex populations, such as individuals with SUDs and
common comorbidities (Destoop et al., 2021; Secades-Villa et al., 2020) and younger
patients (Stanger & Budney, 2019). Finally, given the inherent financial cost of
vouchers, it also bears mentioning that cost-effectiveness analyses have been support-
ive of contingency management (González-Roz et al., 2021; Lott & Jencius, 2009;
Olmstead & Petry, 2009; Sindelar et al., 2007).
Two important distinctions are worth noting about contingency management.
First, unlike CRA, which has a relatively codified treatment package, the exact
format of contingency management varies substantially from study to study. This is
a deliberate feature of contingency management insofar as it is intended to be
mapped onto the different priorities across programs and populations, but it means
that there is a high degree of heterogeneity in formats. Formats using both the
voucher reinforcement method and the prize-based reinforcement method have both
been shown to be efficacious (Benishek et al., 2014; Lussier et al., 2006). As such,
although the balance of evidence supports contingency management as being
 Substance Use Disorders 201

Box 12.2 Harm Reduction

Harm reduction refers to strategies aimed at reducing adverse health and social
outcomes associated with substance use without necessarily identifying abstinence as
the goal (Thomas., 2005). Harm reduction can take many forms, including both public
health strategies (e.g., drug testing, naloxone kits, needle exchanges) and clinical
strategies (e.g., focusing on a reduction or moderation outcome rather than complete
abstinence). Harm reduction has been shown to reduce the risk of overdose and other
harmful consequences (morbidity and mortality) associated with use, as well as to
improve treatment initiation, adherence, and retention (Denis-Lalonde et al., 2019;
Hawk et al., 2017; Hunt et al., 2003; Kimmel et al., 2021). Although abstinence typically
remains a priority outcome in clinical research evaluating efficacious treatments,
contemporary perspectives emphasize a patient-centered approach in clinical practice.
This would include a spectrum of outcomes, from no change in use with minimization
of harms to a reduction in consumption without abstinence to complete abstinence.
Moreover, these outcomes need not be mutually exclusive over time. For example, lack
of success with a moderation goal may evolve into an abstinence goal, or successful
long-term abstinence may be followed by the goal of resuming moderation.

beneficial, implementation of contingency management should be based on the

evidence that comes from the most germane settings, conditions, and populations.
Second, it is important to note that contingency management is typically not
intended to be a stand-alone treatment, but to be one element in a broader treatment
package (González-Roz et al., 2021; Lott & Jencius, 2009; Olmstead & Petry, 2009;
Sindelar et al., 2007).
A gap in the literature pertains to which specific features of both CM and
CRA are essential for clinical benefits. For CM, there is some evidence that
larger magnitude rewards are more effective (Businelle et al., 2009; Petry et al.,
2004; Regnier et al., 2022), but also evidence that magnitude has a ceiling
(Carroll et al., 2002; Petry et al., 2015). Incentive amount received and spending
have also been found to be predictive of benefits (Lake et al., 2023; Petry &
Roll, 2011), but how to optimize CM is by no means definitive. For CRA, the
status is similar to CBT insofar as the evidence for the package is robust, but
less is known about which specific alternative reinforcers are most potent or
important for promoting positive outcomes.

Approaches for Youth

Substance use most often initiates during adolescence (UNODC, 2020), and the
peak prevalence of SUDs is during emerging adulthood, spanning ages 18–25
years (Grant et al., 2015; Hasin, 2018; Sarvet & Hasin, 2016). This transition
202 Stead, Lumb, Brasch, and MacKillop

from childhood to adulthood is marked by numerous physiological, academic,

vocational, interpersonal, and neurobiological changes that increase the likeli-
hood for substance use and, in turn, risk for negative substance-related outcomes
(Arnett, 2000; Dawson et al., 2007). Adolescents and emerging adults are also
more likely to engage in polysubstance use (Kelly et al., 2015; Zuckermann
et al., 2019, 2020), which is associated with worse physical and mental health
problems and more risky behaviors (e.g., risky sexual behaviors, driving under
the influence) (Bohnert et al., 2014; Connell et al., 2009). Adolescents who
engage in substance use earlier on and/or use multiple substances show worse
academic performance, have lower rates of high school completion, and can
experience negative long-term effects on their overall cognitive functioning
(Bohnert et al., 2014; Morin et al., 2019). Importantly, those who initially
engage in substance use during early adolescence are also more likely to go
on to develop SUDs in young adulthood and adulthood (Choi et al., 2018;
Merrin et al., 2018; Zuckermann et al., 2020). Importantly, substance use during
these developmental periods is not a benign experimentation but, rather, is
a leading cause of disability among individuals during this time (Erskine
et al., 2015). For example, alcohol is implicated in a quarter of deaths among
Americans aged 20–34 (Esser et al., 2022). Collectively, there is a strong need
for intervention because of the high rates of morbidity and mortality, but also to
interrupt adverse trajectories that may affect an individual across the lifespan.
Few of the treatments for SUDs have been specifically tested for adolescents and
young adults (Catchpole & Brownlie, 2016). Because substance use is typically
illegal for adolescents, prevention and abstinence-based interventions have been the
primary approach, but this approach can be stigmatizing, demotivating, and leave
young people at an increased risk for relapse and overdose (Corace et al., 2018;
Faggiano et al., 2014; Stigler et al., 2011). It has been recommended that, instead,
the full range of treatment options should be available to young people, including
harm reduction (Bruneau et al., 2018; Corace et al., 2019). Even without extensive
developmentally specific research, adaptations of the psychological approaches
detailed herein – such as the Adolescent CRA, ecological family-based treatment,
individual CBT, and group CBT – are generally beneficial in adolescent and young
adult populations (Godley et al., 2014; Silvers et al., 2019; Waldron et al., 2007).
There has been less research on behavioral family-based treatment and motivational
interviewing, but both approaches appear to be moderately efficacious (Hogue et al.,
2019). In addition, emotional regulation skill-based interventions, informed by
dialectical behavior therapy, have been shown to be promising for youth with
concurrent disorders (Hawkins, 2009; Henderson et al., 2019). Importantly, it has
been demonstrated that incorporating young adult perspectives in the development
of SUD services enhances overall treatment uptake, engagement, and satisfaction
(Hawke et al., 2019).
 Substance Use Disorders 203

Other Variables Influencing Treatment

Assessment and Diagnosis
Assessment plays a critical role in treatment in a number of ways, including
screening for and diagnosing SUDs, identifying co-occurring conditions, identify-
ing functional relationships that maintain substance use, defining and prioritizing
specific treatment outcomes, providing patients with objective feedback about
substance use, and evaluating progress over the course of treatment. Idiographic
assessment using a battery of psychometrically validated tests is a foundational
component of empirically supported psychological treatment.
Commonly used screening tools include the Alcohol Use Disorders Identification
Test (AUDIT; WHO, 2001), the Cannabis Use Disorders Identification Test
(CUDIT; Adamson et al., 2010), the Drug Use Disorders Identification Test
(DUDIT; Berman et al., 2005), the Drug Abuse Screen Test (DAST; Skinner,
1982), and the Alcohol, Smoking and Substance Involvement Screening
Test (ASSIST; NIDA, 2009). Following initial screening, comprehensive assess-
ments that incorporate diagnostic and multidimensional approaches are necessary,
and are particularly important for differential diagnosis of SUDs and other psychi-
atric conditions (APA, 2013; Daley & Douaihy, 2019; Liese & Beck, 2022; Reus
et al., 2018). For example, patients commonly endorse depressive symptoms, but
these may be the result of negative consequence from substance use, withdrawal
symptoms, or fully independent symptoms reflecting major depressive disorder,
requiring careful assessment for disambiguation. Thus, a fulsome assessment of
history and onset of use, patterns of use (frequency, amount, route of administra-
tion), negative consequences from use, physiological dependence (features of toler-
ance and withdrawal), psychiatric symptoms and history, and medical history is
warranted. This may be obtained using an integrated assessment, such as the
Addiction Severity Index, or a bespoke battery of validated measures. Accurate
diagnostic evaluations are also necessary to identify the most appropriate level of
care depending on presenting substance use (or polysubstance use), and symptom
severity (e.g., withdrawal management for acute withdrawal versus outpatient
treatment versus residential inpatient treatment).
In terms of treatment process, functional analysis is strongly recommended to
understand the patterns of active substance use, drugs of choice (i.e., primary/
secondary substances), and functional profiles of use to prioritize treatment targets
with patients. Understanding the antecedents (i.e., prepotent internal and external cues
and triggers), behavioral patterns, and consequences through the lens of positively and
negatively reinforcing motivational functions provides a blueprint for the most
appropriate credible treatment components (e.g., relevant coping skills, need for
motivational enhancement, availability of alternative reinforcers). Increasingly,
a measurement-based care (MBC) approach is being applied to SUDs (Clarke et al.,
204 Stead, Lumb, Brasch, and MacKillop

2021; Marsden et al., 2019), which refers to structured repeated assessment of key
process mechanisms (e.g., motivation, self-efficacy, cravings) that can be thought of
as “recovery vital signs” and substance use itself and comorbid symptoms. This
ongoing process and outcome measurement provides quantitative metrics that can
reveal positive patient progress (and be incorporated therapeutically), but can also be
used to change direction or implement a new component if the trajectory is unfavor-
able. Importantly, MBC is a framework, not a single protocol, and can take many
forms, akin to the many ways contingency management can be configured for specific
clinical questions (Lewis et al., 2019). The use of standardized validated measures is
the common recommendation across MBC protocols. Furthermore, MBC-based
approaches offer an opportunity to develop practice-based evidence about clinical
innovations in real-world clinical settings.

Comorbidity
A major factor affecting SUD treatment response is the presence of co-occurring
psychiatric disorders, referred to by several terms including concurrent disorders,
dual diagnosis, and dual disorders. The presence of an SUD with one or more other
comorbidities is clinically common (Keen et al., 2022; Rush et al., 2008; Skinner
et al., 2004) and is associated not only with poorer treatment outcomes but also with
increased risk of suicidal behavior, interpersonal violence, hospitalization, traumatic
brain injury, criminal justice system involvement, and overdose death (Connery et al.,
2020; Keen et al., 2022). The most commonly prevalent co-occurring disorders are
mood, anxiety, and stress-related disorders, but there are numerous possible combin-
ations of co-occurring SUD and other psychiatric disorders (Keen et al., 2022).
Heterogeneous clinical presentations, combined with the varying severity of co-
occurring disorders, and the degree of available psychosocial supports further com-
plicates the clinical picture (Drake et al., 2007; McKee, 2017; Mueser et al., 2003).
Currently, there are few well-validated integrated treatment protocols for specific
combinations, although promising examples exist, including concurrent treatment of
SUD with major depressive disorder (Daughters et al., 2018; Samokhvalov et al.,
2018) and with posttraumatic stress disorder (Back et al., 2019). More generally,
integrated treatment offering evidence-based approaches that target both the SUDs
and mental health symptoms simultaneously is the recommended strategy (Magill
et al., 2020; McKee, 2017; Mueser et al., 2003).

Demographics
There is robust epidemiological evidence that specific demographic subpopulations
are at a greater risk for SUDs, including individuals experiencing socioeconomic
adversity and discrimination, sexual minorities, those with lower educational
 Substance Use Disorders 205

attainment, males, and adolescents and young adults (Medley et al., 2016; SAMHSA,
2020; Witkiewitz et al., 2022). At present, however, there is limited evidence that
would specifically recommend (or contraindicate) the preceding evidence-based
components for specific demographic subpopulations. Rather, a common theme to
all of the components is the importance of a thorough idiographic assessment and
incorporation of these important features of identity and personal history into
a treatment plan. For example, a functional analysis in CBT should fully incorporate
demographic considerations, including a person’s sex and gender, race and ethnicity,
and socioeconomic factors, as potential determinants of substance use. As noted, the
most fulsome example of this is that many treatments were not developed for or
validated in youth specifically but are nonetheless implemented with incorporation
of youth considerations. Furthermore, recent research has started to investigate
subpopulation-specific interventions, such as a “two-eyed seeing” approach for
Indigenous people that incorporates the historical context and experiences of
Indigenous people (Hawke et al., 2019; Marsh et al., 2015). A challenge, of course,
is that there is substantial heterogeneity within subpopulations, so tailoring of inter-
ventions has to be careful not to assume that all individuals of a certain identity will
experience common determinants. Nonetheless, there is no question that demographic
factors such as race, sex, and sexual orientation are implicated in SUD risk and need to
be incorporated into SUD treatment.

Medication
When approved medications are available, integrated psychological and pharmaco-
logical treatment is warranted (MacKillop et al., 2018), unless a patient has a medical
contraindication or strong preference to the contrary. Unless a pharmacotherapy is
available in an over-the-counter format, this is typically via collaborative care with
a physician. For opioid use disorder, buprenorphine (a partial opioid agonist com-
bined with naltrexone to deter intravenous use) and methadone (a full opioid agonist)
are first-line treatments to alleviate withdrawal (Bruneau et al., 2018; Perry et al.,
2022; Soyka & Franke, 2021). For tobacco use disorder, nicotine replacement therapy
(NRT) is an over-the-counter first-line treatment that is available in multiple formu-
lations, including patch, gum, lozenge, oral spray, and intranasal inhaler. It is typically
used in a dual-formulation strategy (i.e., slow-acting transdermal patch plus a faster-
acting formulation for breakthrough cravings) (Rigotti et al., 2022). Varenicline and
buprenorphine XL are medications that have also been shown to be efficacious
(Rigotti et al., 2022), typically in combination with a behavioral treatment program.
For moderate-to-severe AUD, both naltrexone (a partial μ opioid receptor antagonist)
and acamprosate (an N-methyl-D-aspartic acid receptor modulator) are recommended
first-line medications (Reus et al., 2018). Disulfiram, which disrupts alcohol metab-
olism and produces an aversive reaction if alcohol is consumed, has inconsistent
206 Stead, Lumb, Brasch, and MacKillop

efficacy and is only recommended for individuals who are seeking abstinence, have
not responded to naltrexone and acamprosate, and are capable of understanding the
potential risks of drinking while taking disulfiram (Reus et al., 2018). Topiramate and
gabapentin are also second-line options (Reus et al., 2018).
Most germane to psychological treatment, in a recent meta-analysis, CBT and
other specific therapies in combination with pharmacotherapies were found to
produce significantly improved overall treatment outcomes when compared to
psychological treatment or medication alone (Ray et al., 2020). Beyond concur-
rently offering psychological and pharmacological treatment, however, it is not
clear how medication integration effects psychotherapy process or outcome. Direct
synergistic integration of pharmacological and psychological treatment has been
demonstrated in early-stage proof-of-concept studies (e.g., MacKillop et al., 2015),
but research in this area is nascent and the standard-of-care is parallel pharmaco-
logical and psychological treatment.

Conclusion
A core portfolio of psychological treatments is available for treating SUDs.
These interventions – CBT, motivational interviewing, and reinforcement-based
approaches – are premised on robust theoretical and etiological frameworks and
supported by methodologically rigorous intervention research. Although there
are important nuances in the treatment outcome literature, the balance of the
evidence supports these approaches. From these approaches come core compe-
tencies for clinical psychologists, and standard training in these techniques is
warranted, akin to other common psychiatric conditions. Given that only a small
minority of individuals with SUDs receive treatment and in many treatment
programs empirically supported practices are often not employed (Knudsen &
Roman, 2016; Olmstead et al., 2012), expanding training in these competencies
and increasing the workforce of mental health providers implementing these
strategies is critical.

Useful Resources

Book/Manual
• Daley, D. C., & Douaihy, A. B. (2019). Managing your substance use disorder: Client
workbook (3rd ed.). Oxford University Press.
• Miller, W. R. (2004). Combined behavioral intervention manual: A clinical research
guide for therapists treating people with alcohol abuse and dependence. National
Institutes of Health.
 Substance Use Disorders 207

Websites
• National Harm Reduction Coalition: Overdose prevention: https://harmreduction.org/issues/
overdose-prevention/
• NIAAA Core Resource on Alcohol: www.niaaa.nih.gov/health-professionals-communities/
core-resource-on-alcohol
• NIAAA Treatment Navigator: https://alcoholtreatment.niaaa.nih.gov/
• SMART Recovery: www.smartrecovery.org/
• Surgeon General’s Report on Addiction: https://addiction.surgeongeneral.gov/sites/default/files/
surgeon-generals-report.pdf
• Veterans Affairs: www.healthquality.va.gov/

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 13
Cognitive Loss
Claudia Drossel

Behavioral health providers and trainees will likely encounter individuals who present
with subjective cognitive complaints that may emerge from the sequelae of multiple
etiologies. As time spent living generates risk factors such as injuries, exposure to
neurotoxins, and chronic diseases, subjective cognitive complaints are common in
midlife and represent a significant public health concern (Taylor et al., 2018). The
cognitive repertoires at risk of decline are foundational to building and maintaining
relationships across home, work, school, or leisure settings. These repertoires include
attending, perceiving (e.g., spatial relations), planning, reasoning, organizing, problem-
solving, comprehending, learning, remembering, communicating, self-reflection, and
taking perspectives different from one’s own.
Corresponding to the World Health Organization’s (2019) distinction between
cognitive decline and dementia, the American Psychiatric Association (2022) distin-
guishes mild from major neurocognitive disorders (NCDs) as syndromes across
a spectrum of severity (see Bermejo-Pareja et al. [2021] for the distinction between
“mild NCD” and an alternative construct, “mild cognitive impairment”). While both
mild and major NCD diagnoses require a decline from a previous baseline functional
status confirmed by objective evidence (such as neuropsychological data), the diag-
nosis of mild NCD characterizes subtle inefficiencies, greater effort or more errors
during task completion, or the use of new compensatory strategies with continued
independence in activities of daily living and decision-making. When cognitive
decline is sufficient to disrupt instrumental activities of daily living, such as meal
preparation, financial management, medication adherence, and household chores, it
meets criteria for major NCD (formerly “dementia”) if delirium or other acute
conditions are not present. About 11% of adults older than 45 years of age voice
subjective complaints (Taylor et al., 2018). Of individuals older than 65 years of age,
about 22% meet the criteria for mild cognitive impairment, and 10% meet the criteria

Author Note: Thank you to Thomas Waltz, Jacqueline Pachis, and Kayla Rinna for comments on an earlier draft of this
chapter.

218
 Cognitive Loss 219

for major NCD (Manly et al., 2022). However, inconsistent diagnostic definitions and
methodological limitations call into question the accuracy of current global estimates
(Pais et al., 2020).

Etiology and Theoretical Underpinnings of Treatment

A proper diagnostic workup is essential to determine the nature of cognitive decline.
In addition to neurodegenerative diseases, such as Alzheimer’s disease (AD) or Lewy
body disease (LBD), causes of cognitive loss include physical trauma (e.g., related to
motor vehicle accidents, falls, or assaults), long-term metabolic disturbances (e.g.,
poorly managed diabetes, thyroid disease), cardiovascular or cerebrovascular events
(e.g., cardiac arrest or stroke), exposure to neurotoxins (e.g., mood-altering sub-
stances, pesticides), neoplasms (e.g., brain tumors), and certain medical treatments
(e.g., radiation or chemotherapy, long-term antiretroviral therapies) (for an introduc-
tion, see Miller & Boeve, 2017).
The progression from subjective complaints to mild NCD, and from mild to major
NCD, is poorly understood. Population-based studies suggest that some individuals
with mild NCD maintain their cognitive status, others recover baseline functioning
(Overton et al., 2020), and yet others progress to irreversible neurodegenerative
diseases. Some NCD subtypes are further classified by dominant behavioral changes,
such as marked impulsivity and neglect of social mores, or progressive language
deficits (i.e., variants of frontotemporal lobar degeneration) (Boeve et al., 2022).
Recently, emotional and behavioral changes, specifically irritability and apathy
(Roberto et al., 2021), have received attention as predictors of progression. The
absence of uniform diagnostic criteria for clinical trials and variability in ruling out
reversible sources of cognitive loss remain persistent threats to the validity of research
in this area (but see McKeith et al., 2020), and the intervention literature that takes into
account specific etiologies is slowly expanding.
Empirically based principles of behavior change to guide effective, individually
tailored practice with individuals with NCD have been examined for more than half
a century (Lindsley, 1964), often with small-N research designs. The operant model,
emphasizing that the meaning of behavior (B) emerges when its probabilistic
antecedents (A) and consequences (C) are analyzed across time, has been dissemin-
ated as the functional approach (Bourgeois & Hickey, 2009), the contextual model
(Fisher et al., 2007; McCurry & Drossel, 2011), or as the ABCs (i.e., antecedents-
behavior-consequences), within caregiver intervention packages and cognitive
behavior therapies for people with NCD (Ehrhardt et al., 1998). According to the
philosophy of behavior analysis (Baum, 2017; Chiesa, 1994), a functional model
interprets the emotional and behavioral changes that accompany and often precede
detectable cognitive decline as predictable and changeable results of subtle and
seemingly inexplicable disruptions of one’s social life and routines (see also
220 Claudia Drossel

Kitwood & Brooker, 2019). Rather than describing individuals with cognitive loss
as intentionally withdrawing or becoming hostile, a functional model views persons
as continuing to value active task or community engagement, human connection,
and intimacy, regardless of the degree to which cognitive decline has become
a barrier to being effective. Interventions occur across interrelated social–
cognitive–behavioral–affective domains, depending on the person’s history and
current needs.

Brief Overview of Treatments

Effective treatments for emotional and behavioral changes associated with cognitive
loss understand these changes in terms of their current consequences or impact (What
does the behavior accomplish? For example, does a given behavior aid the person in
withdrawing from a difficult situation?) and antecedents – the person’s interpersonal
coping history and current social circumstances, such as role shifts and interpersonal
demands. They eschew default physiological explanations (i.e., blanket attributions of
emotional and behavioral changes to the NCD per se). Instead, they apply Hussian’s
(1981) seminal observation that when emotional and behavioral problems are unchar-
acteristic of the person and severe enough to consult a behavioral health specialist,
they should lead to a systematic and thorough investigation of a potential acute change
in physical status and of the possibility of adverse or coercive social interactions. Even
when cognitive loss is moderate to severe, emotional and behavioral changes can be
understood in terms of these events, and quality of life can be achieved by building
appropriate social and instrumental supports. Focusing on idiographic assessment and
related behavioral processes (e.g., stimulus control, reinforcement) rather than topog-
raphies (e.g., patient personality, caregiver style) allows for more nuanced and
individualized assessment and linked interventions when complexity is high.

Description of Treatment Packages

Depending on the severity of cognitive loss, treatment packages whose primary
targets are emotional and behavioral changes may involve the person with NCD, or
they may consist of caregiver interventions that exclude the person with NCD from
assessment and intervention and rely solely on the care partners’ reports. Existing
cognitive-behavioral therapies have been adapted for individuals with mild to moder-
ate cognitive loss (for adaptation strategies, see Gallagher et al., 2019) and sometimes
involve informal or formal care partners to ensure carryover and implementation of
between-session assignments (Orgeta et al., 2022). However, to the extent that these
adaptations maintain their original psychopathological models (e.g., foci on maladap-
tive beliefs or lack of psychological flexibility), they are at risk of being unresponsive
to the actual social and instrumental challenges posed by cognitive decline that
 Cognitive Loss 221

require active advocacy and targeted problem-solving (for an alternative approach,

see Hayes et al., 2020).
Additionally, a distinct class of treatments targeting improvements in cognition or
activities of daily living as primary outcomes is also available (Tulliani et al., 2022),
with a parallel neglect of emotional and behavioral status as potential barrier to or
facilitator of engagement (but see Kurz et al., 2012; Tonga et al., 2021). These
treatments are characterized as “remediation,” an umbrella term for interventions
targeting cognitive or functional status: (1) training via learning and memory tech-
niques that aim to improve specific cognitive domains; (2) rehabilitation via compen-
satory or adaptive strategies that do not target improvements in cognition but scaffold
daily task completion; and (3) stimulation via social engagement and games or
preferred activities, such as gardening or cooking – effectively, activity scheduling
with a cognitive rationale, to reduce loneliness and improve quality of life (Tulliani
et al., 2022). Notably, rather than applying comprehensive idiographic functional
assessment and treatment strategies across closely related cognitive (activities of daily
living) and emotional-behavioral targets, most intervention packages for the person
with NCD tend to be siloed within specific status domains (i.e., emotional/behavioral–
cognitive–functional).
When cognitive loss is moderate to severe, multicomponent caregiver interventions
predominate to improve the quality of life of both care partners and the person about
whom they care, and to mitigate care partners’ physical and emotional strain (Xu
et al., 2020). Care partners often are unprepared to understand the range with which
neurological diseases affect a person’s functioning, to act as assessors and interven-
tionists to appropriately scaffold repertoires, and to complete nursing tasks. Many
family care partners provide extensive assistance under untenable conditions of
financial losses and lack of specialized respite services (Gaugler & Kane, 2015;
Glenn, 2010). For this reason, treatment modules broadly cover education, stress
management strategies, problem-solving, and essential behavioral skills to manage
care recipients’ emotional or behavioral changes.
Behavioral skills training components of well-studied and translated intervention
packages (such as Resources for Enhancing Alzheimer’s Caregivers Health, REACH
II; e.g., Belle et al., 2006) or Staff Training in Assisted Living Residences (STAR;
e.g., Teri et al., 2005) represent consistent efforts to disseminate and implement
a science-based approach to emotional and behavioral changes in the context of
cognitive loss, by teaching functional “ABCs” to formal or informal caregivers
(Moniz Cook et al., 2012). Ideally, caregivers learn to systematically monitor behav-
ior and emotion in their antecedent and consequent situational contexts, and to design
and evaluate interventions based on the resulting patterns. Components such as
interventions based on stimulus control or differential reinforcement inherent in
these treatment packages, are detailed in the “Credible Components of Treatments”
section of this chapter.
222 Claudia Drossel

Overall Level of Research Support

Despite the unequivocal call for nonpharmacological interventions across inter-
national practice guidelines, the state of the evidence could still be improved after
almost 30 years of research on individual psychological interventions (Orgeta et al.,
2022) and 50 years of research on caregiver interventions (Cheng et al., 2022; Meng
et al., 2021). Cognitive-behavioral interventions involving persons with mild or major
NCD produce small effects on depression, with moderate-certainty evidence (Orgeta
et al., 2022), and details related to active components have not been sufficiently
investigated. Among cognitive remediation strategies, only cognitive rehabilitation
(Jeon et al., 2021; Kudlicka et al., 2023) and stimulation (Woods et al., 2023) have
empirical support for improving functional status and quality of life, respectively.
Cognitive training, which consists of practicing specific cognitive tasks, enhances
task performance and global cognition for individuals with mild to moderate cognitive
loss (Bahar-Fuchs et al., 2019). It is unclear whether cognitive training generalizes to
everyday situations, and it is currently not recommended for individuals with major
NCD (National Institute for Health and Care Excellence, 2018; Sala & Gobet, 2019;
von Bastian et al., 2022).
The effects of multicomponent caregiver interventions go beyond those of phar-
macotherapies for emotional and behavioral changes associated with NCD (Gerlach
& Kales, 2020). Caregiver interventions consistently produce small (Cheng et al.,
2022; Meng et al., 2021) or small to moderate benefits on care partner competency/
knowledge, well-being, burden, and mood, and on care recipient behavioral/emo-
tional status (Walter & Pinquart, 2020).
Overall, continued population heterogeneity due to new and evolving diagnostic
categories, failure to distinguish etiological subtypes of NCD, or including both
mild – and thereby potentially reversible – and major NCD; heterogeneity in targeted
domains and outcome measures; uncertainty about the degree to which care partner
outcomes generalize to care recipient well-being; and complexity in terms of comor-
bidities and sedative medication status still hamper an answer to the question for
whom, when, and under what conditions particular treatments work (Paul, 1967).
Functional-contextual approaches are individually tailored and tend to be evaluated
within small-N designs or integrated in multicomponent interventions. To date, large-
N trials of functional-contextual interventions are lacking (Holle et al., 2017; Moniz
Cook et al., 2012), and systematic dismantling studies have not been conducted.
However a study that omitted “ABC” training from an empirically supported inter-
vention for caregivers (Prick et al., 2016) failed to replicate the original study’s effects
on care recipient behavior, health, or mood (Teri et al., 2003). While Prick et al.
attributed the failure to replicate to translational and cultural issues, it is as likely that
the eliminated experimental ABC training would have equipped caregivers with the
problem-solving needed to implement interventions flexibly, tailored to the individual
 Cognitive Loss 223

situation (contrast with Kurz et al., 2012, who did attribute their lack of intervention
effects to a failure to individualize treatment goals).

Credible Components of Treatments

Credible components of treatments are those that effectively educate the person with
NCD and their care partners about the specifics of cognitive loss and its intersection
with the person’s life. In line with disability advocacy, they counteract narrowing
repertoires and re-engage the person with NCD in a range of meaningful activities,
whether intentionally rehabilitative in nature or important for maintaining that
specific person’s quality of life. Because NCDs represent a heterogeneous collec-
tion of individual strengths and weaknesses that interact with a person’s social and
medical histories and current circumstances, individualized functional assessments
often are necessary for flexible problem-solving within a person’s given context.
Interventions that suggest a multipronged one-size-fits-all approach may be effect-
ive some of the time but are at risk of missing important contextual determinants of
individual well-being, such as social consequences that are distributed in time and
only become visible with repeated systematic observations (for an analysis of
coercive processes in the family, see Patterson, 1982). Particularly when problems
appear intractable and not amenable to nonpharmacological solutions, repeated
systematic observations detect contingencies that elude snapshot assessments and
suggest points of intervention.
The intervention components that follow are contained within existing treatment
packages to varying degrees. They may target the person with NCD directly, or
indirectly via the care partner.

The Basics
Reducing Vascular Risk Factors and Preventing Excess Disability
Health conditions whose poor management may exacerbate or contribute to cogni-
tive decline are often overlooked. In 1996, The American Academy of Neurology
Ethics and Humanities Subcommittee recommended medical and behavioral health
follow-up for all individuals with NCD, to decrease concurrent vascular risk factors
and to prevent excess disability (i.e., functional decline exceeding that predicted by
a given neurodegenerative disease alone) (Kahn, 1965; Ngandu et al., 2015).
Throughout the course of NCD, lifestyle factors and concurrent conditions that
may contribute to cognitive, emotional, or behavioral decline must be taken into
account, including optimizing nutrition and hydration; addressing bowel and urin-
ary concerns to prevent restlessness and agitation; maximizing sleep; carefully
limiting the number and dosage of medications; treating comorbid medical
224 Claudia Drossel

conditions (e.g., hypo- or hyperglycemic episodes; pulmonary disease; see

Frederiksen & Waldemar, 2021); managing acute or chronic pain or discomfort;
addressing hearing and vision to facilitate communication and prevent mispercep-
tions (Littlejohn et al., 2021); decreasing substance use; and increasing physical
activity and enhancing outdoor mobility.
Any abrupt decline in functioning should lead to the systematic investigation of
adverse events that may disrupt cognition further, such as stroke or seizures, or
failure to tolerate novel or previously tolerated medications (see also the related
literature of delirium occurring in cases of those with cognitive impairment; Oh
et al., 2017). Individuals with cognitive loss who have access to academic or
larger healthcare settings will find many of the needed services within one health
system; however, many community-dwelling adults in suburban or rural areas
may need to put together a healthcare team and coordinate communication across
team members.

Education and Healthcare Navigation

If cognitive losses do not interfere with self-management and goal-directed behavior,
individuals may participate in all aspects of assessment and related medical and
behavioral health services without care partner support. However, such autonomy
can become problematic when decline is progressive and irreversible. For example, if
a person with mild NCD and insulin-dependent diabetes later develops difficulties
measuring blood glucose levels and calculating the sliding-scale insulin dose, when
and how will the care partner take over the task? Many care partners learn about
diabetes management from the person with NCD at a point when reporting has
become unreliable (Feil et al., 2009; Munshi, 2017). The risks of misremembering
and unreliable reporting suggest that care partners best learn about the person’s
medical and behavioral health needs and routines before self-direction is disrupted.
Moreover, an NCD diagnosis may lead a care partner to attribute behavioral and
emotional changes to cognitive decline rather than frequent undetected or poorly
managed medical conditions. For this reason, education and medical care navigation
are important components of interventions for NCD, and should be tailored to the
individual (e.g., managing common comorbidities of specific neurological diseases,
such as constipation or REM sleep behavior disorder with LBD) and involve a care
partner early. The completion of advance directives (e.g., for healthcare or for
research) aids care partners’ and providers’ consideration of individuals’ values and
preferences throughout the care trajectory (Reamy et al., 2013). Care partners must
learn about care fragmentation to effectively coordinate services across multiple
providers and receive advocacy for accessing third-party care. For some care partners,
assertiveness training may be necessary to shape an accurate description of the dyad’s
functional status and needs for assistance, and to solicit support across agencies that
 Cognitive Loss 225

may cover different functional domains. Many care partners must acquire the skills to
hire and manage third-party carers (Bieber et al., 2019) or to direct the person with
NCD’s care in institutionalized settings or at the end of life.

Advanced Problem-Solving: Applications of Behavioral Science

The following subsections represent the application of structured and systematic, yet
flexible functional analysis-based problem-solving (Haynes & O’Brien, 1990;
Haynes et al., 2011).

Problem-Solving Stance and Application

Problem-solving strategies are essential to service provision involving persons with
cognitive loss (e.g., Areán et al., 2010). Initial repertoires for effective problem-
solving are the problem orientation (i.e., detecting the need for change) and
a problem definition (clearly delineating the target of change) (D’Zurilla &
Goldfried, 1971). The stigma of cognitive loss combined with sociocultural pressures
for conformity, and ableist or often ageist assumptions, require detailed attention to
the questions “What is the problem, and whose problem is it?” If, for example,
a person who walks five miles per day develops difficulties finding their way home,
and the family responds by restricting the person’s mobility (e.g., discouraging or
preventing leaving the house), whose problem are the resulting restlessness and
difficulty sleeping? These questions are compounded in residential settings that
severely restrict choices and thereby not only disrupt individuals’ lifelong routines
but also compromise or violate individuals’ values and preferences. Social demands
directing the person to “gain insight” into their difficulties (e.g., losing one’s way) are
often demands to relinquish activities (e.g., stop going for walks) when they become
inconvenient and cumbersome because they cannot be self-directed or executed
without assistance. For an introduction to ethics in geropsychology, see Bush et al.
(2017).
Providers who teach problem-solving strategies to the person with cognitive loss
and/or their care partner must be aware of their own biases and assumptions (e.g., the
contraindicated stance that one must “slow down” with age or after a diagnosis) and of
the tension inherent in dyads when the person with cognitive loss seeks continuity of
usual activities and habits under new circumstances and thereby disrupts routine
arrangements, such as walking alone. Problem-solving then focuses on finding
acceptable scaffolding or assistance, soliciting friends or communal support (e.g.,
walking group), and advocating to maintain quality of life by engaging in valued
activities. Whether an individual solution works is an experimental question: If not,
then further problem-solving considering removal of encountered barriers is required.
Barriers are best viewed as opportunities for learning and not as signs of
226 Claudia Drossel

unchangeability. Sociocultural beliefs related to disability and intersecting aspects of

diversity (e.g., gendered or age-dependent role expectations) should be specifically
explored when building a problem orientation and defining the problem. Subsequent
collaborative and constructive problem-solving will maintain quality of life and
prevent the experience of NCD as one of innumerable losses.

Systematic Observations
Persons with NCD as well as their care partners may be unreliable historians, and
survey tools assessing caregiver needs perform poorly in areas of construct validity,
test–retest reliability, and sensitivity to change (Kipfer & Pihet, 2020). For this
reason, systematic observations play a significant role in services for people with
NCD, providing the data needed to link assessment to intervention. Systematic
observations, by self (self-monitoring) or others, are analytical tools for detecting
the probabilistic functional relations between context (antecedents and consequences)
and emotional or behavioral changes (Bridges-Parlet et al., 1994; Cohen-Mansfield
et al., 2017). Data collection forms the prerequisite for function-based behavioral
management (see “Function-Based Behavioral Management”) and examining the
outcome of interventions.
When cognitive decline prevents regular self-monitoring, the care partner may
assist the person with NCD, or wearable devices may fill the gap if the provider can
present the data to the client in a user-friendly format (e.g., a printout of a graph
showing activity level as a function of weekdays versus weekends when family
members tend to visit). Self-monitoring of, for example, the relation between mood
and care demands, or sleep and mood, is also important for care partners, who tend to
encounter unrealistic and untenable social expectations about their ability to serve as
the sole source of support for the person with NCD for years or decades (for digital
monitoring with feedback, see van Knippenberg et al., 2018).

Function-Based Behavioral Management

Stimulus Control Interventions. The term “stimulus control” describes a probabilistic
relationship between behavior and its context, particularly that behavior is more likely
in one situation than another. Here, a “stimulus” or situation is conceptualized broadly;
for example, a person might routinely drink coffee in the morning (temporal stimulus
control), differentially disclose personal information (audience stimulus control), or be
more likely to eat sweets when working late at night (stimulus control by physiological
factors, such as time since last meal or fatigue). Nervous-system insults tend to result in
marked sensory alterations, making it difficult to discern and thus respond to situational
cues. Many problems arise from that breakdown of stimulus control – the failure of the
context to occasion appropriate behavior. Among these breakdowns are olfactory
 Cognitive Loss 227

alterations with resulting food selectivity, refusal to eat, or lack of engagement in

personal care (for a review of anosmia, see Boesveldt et al. (2017)); visuo-spatial
alterations with resulting misperceptions, visual disturbances, and refusal to enter
certain spaces such as uniformly tiled bathrooms (Weil & Lees, 2021); and alterations
in binaural hearing with resulting preference for one-on-one interactions or refusal to
engage with multiple speakers (Li et al., 2021; Littlejohn et al., 2021).
Many behavioral changes associated with cognitive loss can be understood as
normal reactions to a breakdown in stimulus control. Idiographic assessment can
suggest systematic changes to the antecedent context, with the goal to decrease
confusion and facilitate the person’s detection of situational cues and engagement
in behavior appropriate to that situation. An example is a daughter who notices that
her dad, who lives independently, has stopped reheating his cherished morning coffee,
which she prepares for him in advance. He vaguely complains about the microwave.
Observations show that he approaches the microwave but fails to locate the recessed
button that opens the door. Verbal prompting (“press this button to open” – verbal
stimulus control) is effective but does not carry over to the next morning. However,
placing a red sticker onto the recessed button works: Dad picks up his routine again.
This simple example of visual stimulus control illustrates that teaching the person
with NCD or the care partner how to re-establish cues by making them more salient, or
how to shift to novel and effective cues, can prevent premature dependence and
interpersonal strain.
Many interventions rely on stimulus control as a behavioral process but do not
explicitly identify as such. For ease of dissemination, stimulus control interventions
are integrated within caregiver training packages (e.g., within the antecedent part of
the antecedent–behavior–consequence ABC training) or in cognitive rehabilitation
approaches as environmental modifications (e.g., introducing digital calendar apps
to aid temporal orientation; painting the floor of the bathtub and its walls in different
colors to facilitate spatial navigation), making it difficult to assess their independent
effects. Moreover, across these packages, measured outcomes vary: Target reper-
toires are individualized in caregiver training, where care partners are encouraged to
examine situations that pose new difficulties and require extra efforts from the
person with NCD, or in which emotional responding, withdrawal, and refusal are
common. Sleep interventions for people with NCD also contain some stimulus
control strategies, such as establishing regular sleep/wake times with activity during
the day and wind-down routines in the evening, or reducing sleep disruptors such as
noise, light, or screens. In cognitive rehabilitation, targets generally reflect the
degree to which activities of daily living are self-directed, albeit with assistance
or scaffolding. Thus, the applicability of stimulus control as a behavioral process is
broad and a keystone in most multicomponent interventions. It is understudied as
a stand-alone intervention.
228 Claudia Drossel

To what extent a person is affected by sensory changes must be examined on

a case-by-case basis. Because of heterogeneous presentations and the integration of
stimulus control in multicomponent interventions, evidence for stimulus control
interventions specifically comes from small-N designs (for a detailed review, see
Spira & Edelstein, 2006). The disambiguation of situational cues, based on individ-
ual functional assessment and response to intervention (assessed via outcome
monitoring), can alleviate common behavioral and emotional changes associated
with cognitive loss.
Re-establishing Chains and Sequences. As noted, interventions that re-engage
individuals in everyday activities fall under the umbrella of “cognitive rehabilitation”
(Jeon et al., 2021). Most activities – from dressing, laundry, meal preparation and
medication management to operating technical equipment or computers – are com-
prised of sequences or behavioral chains. The outcome or consequence of one step of
the chain automatically becomes the antecedent for the next step (e.g., closing the
door of the microwave sets the occasion for setting the cooking time, which then
occasions pressing start). A disruption of this functional switch from consequent to
antecedent may generate inexplicable performance failure and confusion. People
often say they seem to be “drawing a blank.” Increased reaction times and latencies
to the next step are common and can also appear in verbal behavior when an utterance
trails off or a person “loses their thread.” Self-directed, effortful, explicit problem-
solving may be necessary to get back on track and complete the task in question.
Implementing daily structure and routines may help to maintain the automaticity of
habits.
When in-the-moment problem-solving fails, task analyses and self-prompting
routines – from least to most intrusive or physical prompts – may re-establish some
or parts of the chain. Alternatively, procedures that re-establish sequencing, such as
errorless learning procedures (also called the procedure of vanishing cues), may be
indicated (de Werd et al., 2013). A recent randomized controlled trial (Voigt-Radloff
et al., 2017) did not find a benefit of errorless over trial-and-error learning (i.e., both
approaches resulted in the reacquisition of instrumental repertoires selected by the
participants with NCD). However, the development of individualized errorless learn-
ing procedures is an advanced skill and adequate treatment fidelity evaluations do not
exist. Systematic reviews of cognitive remediation for mild to moderate cognitive
losses suggest that – in addition to re-establishing the repertoire selected for training
(high-certainty evidence at the end of treatment; Kudlicka et al., 2023) – continued
engagement might have an antidepressant effect, lifting the mood of the person with
NCD (Chan et al., 2020).
When the person with cognitive loss ceases to initiate the independent use of
prompts (e.g., Post-It notes are present but do not guide the relevant behavioral
steps), then external or third-party prompting becomes necessary. Caregiver skills
training in the use of task analyses and prompting hierarchies prevents premature
 Cognitive Loss 229

dependence on others for task completion (Beck et al., 1997; Engelman et al., 1999).
Here, too, a highly individualized approach – determining what works for each person
at a given time to maximize engagement – is recommended. Goal selection must
consider the person’s status, starting with steps that are achievable and thereby
preventing frustration and agitation associated with a failure to progress.
Access to Meaningful Events (Reinforcers). The film Alive Inside: A Story of
Music and Memory (Rossato-Bennett, 2014) fascinated audiences by documenting
that individuals with severe major NCD continued to enjoy music. The erroneous
conclusion by many was that music would have the same effect on all people with
NCD, regardless of personal preferences, history, and current status. Indeed, activity
scheduling is somewhat of a misnomer in that activity per se is insufficient. Selected
activities must connect to the person’s history: that is, ideally, they are meaningful in
some way, continuous with a person’s identities, match the person’s skill level, fit into
the person’s larger sociocultural context, and consider the available social and
material resources and program assistive problem-solving when needed (Teri et al.,
1997; Tierney & Beattie, 2020).
For many adults with NCD, opportunities that are linked to cognition are especially
meaningful. Social and physical activities introduced under the premise of “cognitive
stimulation” (e.g., trivia, card games, walking, social support groups) may affect
general mood and well-being rather than cognition per se (Woods et al., 2023).
Similarly, reminiscence therapy – with an emphasis on personal interaction and life
story – may improve particularly the quality of life of adults with NCD in long-term
service settings (low-certainty evidence; Woods et al., 2018). Because of conceptual
confusion regarding what is meant by person-centered or individually tailored mean-
ingful activities and other methodological problems (e.g., heterogeneity of population
and procedures), systematic reviews so far have produced low-certainty evidence that
individually tailored and meaningful activities may prevent behavioral and emotional
difficulties and increase quality of life when cognitive losses are mild to moderate and
people with NCD reside at home (Möhler et al., 2020). Given an impoverished
environment plagued by staffing difficulties and lack of appropriate choices, empir-
ical support is lacking for individuals residing in long-term service settings (Kim &
Park, 2017; Möhler et al., 2023). Here, small-N studies suggest effectiveness (e.g.,
LeBlanc et al., 2006). In general, implementation efforts at the individual level should
be evaluated.
Differential Reinforcement or Noncontingent Access. Differential reinforce-
ment or noncontingent access are techniques that break the contingent relationship
between a target (i.e., NCD-related) behavior and an outcome. These techniques
maintain the valued outcome or consequence but alter the means by which the
outcome is achieved. From this perspective, the outcome or consequence is valid,
and the person’s right to meaningful engagement is preserved (for an application, see
Gitlin et al., 2008). Small-N studies lend support and suggest that, regardless of the
230 Claudia Drossel

severity of NCD, a person’s behavior remains sensitive to its consequences (e.g.,

Buchanan & Fisher, 2002; Heard & Watson, 1999; Noguchi et al., 2013).
Intervening on Social Contingencies. Rate-decreasing behavioral processes, such
as inadvertent extinction and punishment delivered by family and friends, are plaus-
ible culprits in producing premature functional decline. Evidence from correlational
studies support the notion that the quality of social interactions plays a role in the rate
of decline, and that inadvertent punishment and extinction may be ubiquitous. First,
individuals with higher educational levels commonly experience a steeper verbal
decline (Cadar et al., 2015), implying more opportunities for extinction but also
potentially a stronger reaction to the loss of abilities by families, friends, and col-
leagues. Secondly, “elder speak,” defined as a conversational partner’s changes in
pitch, covaries with disengagement, such that decreased verbal output and increased
refusal of care are common in settings in which older adults are likened to children and
engaged in activities that are not age-appropriate – patronizing at best, infantilizing at
worst (Garrison-Diehn et al., 2022). Third, care partners commonly resort to coercive
techniques, such as yelling, threatening, or using more force than necessary, when
encountering refusal of assistance or refusal to engage or to follow a care partner’s
rules (Patterson, 1982; Thoma et al., 2004), and abuse is common in long-term service
settings (Mileski et al., 2019).
Advocacy and problem-solving predominate when a person’s decline is mild. Later
interventions consist of providing caregivers with communicative strategies (e.g.,
“Do not argue”; McCurry, 2006) and behavioral skills to engage in monitoring of
contextual determinants and functional problem-solving. Communication skills train-
ing improves care partners’ skills and knowledge, but to date methodological limita-
tions prohibit strong conclusions as to effects on dyadic quality of life (Morris et al.,
2018). Further, as study designs have not focused on the quality of relationships as
primary outcomes, empirical support for targeting improvements in the relationship
between the care partner and the person with NCD is still limited (Rausch et al., 2017).
Cognitive Reframing. Interventions targeting verbal behavior (i.e., thoughts,
beliefs, or attitudes) assume that “nothing’s either good or bad, just thinking makes
it so” (Clark & Wright, 1989, p. 1022). The person has been observed to have the
skills and the resources to be effective in a given situation, but verbalizations (“I will
wake up one morning not knowing who I am”; “I shouldn’t have to do this”; “These
are supposed to be the golden years”; “She’s just stubborn as a mule”; “This is never
going to work”) may keep the person from deploying skills or resources that would
improve the situation in the long run. Noticing and identifying unhelpful interpret-
ations, without acting directly upon them (defusing) or challenging them (cognitive
restructuring), are the goals of such interventions (Farmer & Chapman, 2016; Losada
et al., 2015). While not examined in isolation and based on low-quality evidence,
cognitive reframing as part of multicomponent interventions for care partners has
 Cognitive Loss 231

empirical support, showing effects on measures of care partner anxiety, depression,

and distress (Vernooij-Dassen et al., 2011).
Distress Tolerance Skills. When active, problem-focused coping is not available
as an option, distress tolerance skills may be temporarily employed until a solution is
found (Linehan, 1993). Acceptance, distraction, relaxation, arousal reduction, and
other escape or avoidance strategies may increase well-being in the short run but must
be balanced with active problem-solving in the long run, often requiring collaboration
with other members of the family and coordination with employers or additional
service agencies. While relaxation or distress tolerance skills are contained in many
multicomponent interventions for caregivers (see, for example, Steffen (2000) for
anger management), the evidence for stand-alone treatments such as mindfulness-
based stress reduction, characterized as promising in terms of temporary reduction of
depression and anxiety, is of low to very low quality (Liu et al., 2018). To the extent
that studies of multicomponent psychosocial interventions have failed to identify
specific caregiver stressors (e.g., competing workplace or family demands, financial
strain, medical comorbidities) and to detail necessary treatment components to
increase resilience and effective coping, the current state of the evidence cannot
lend empirical support to specific effects (Gilhooly et al., 2016).

Other Variables Influencing Treatment

Assessment and Diagnosis
The heterogeneity of cognitive loss, its etiology, and its effects on a person’s life –
including partners, family, friends, colleagues, and neighbors – requires special
attention to assessment. As noted earlier, assessment of emotional and behavioral
status should occur in the context of multiple specialty providers (e.g., primary
care, neurology, neuropsychology). It is essential to remember that significant
cognitive decline is not a part of aging and is always a sign of nervous system
compromise. The assessment of behavioral and emotional status in this context
and the selection of interventions requires additional training. Variables to con-
sider are: (a) the severity of cognitive decline (Cary et al., 2019), or the degree to
which cognitive decline is expected to remain stable, worsen, or potentially revert,
varies substantially within and across NCD etiologies and may alter the appropri-
ateness of treatment targets and modalities as well as client priorities and prefer-
ences for treatment, and (b) the extent to which a person with cognitive loss can
participate in treatment and self-direct between-session assignments might sug-
gest adaptations, including determination of whether or when care partner
involvement or a caregiver intervention is warranted. The following subsections
represent additional considerations during assessment.
232 Claudia Drossel

Comorbidity
Medical Conditions
Cognitive loss is a sign of a potentially serious neurological compromise that
warrants medical attention. While cognitive loss correlates with age, it is not part
of aging and thus should receive a comprehensive assessment with the goal of
developing a treatment plan to optimize the person’s well-being (American
Psychiatric Association, 2022). From a behavioral health perspective, cognitive
loss is better conceptualized as an insult to the whole body than to the brain:
Chronic medical conditions frequently accompany NCDs (for example, diabetes
and hypertension with vascular disease [Romay et al., 2019]; bowel and urinary
difficulties with LBD [Nardone et al., 2020]). Their management deteriorates as
a person’s self-management skills decline, and they might be overlooked or
undetected when persons lose their self-descriptive skills, increasing the risk of
serious adverse health events and further decline. Self-observation and reliable
reporting on one’s own physical, emotional, or behavioral status are sophisticated
skills and often among the first to be compromised (Defrin et al., 2015), and
disruptive or uncharacteristic behavior patterns are better interpreted as behavioral
indices of unmet needs (Algase et al., 1996).
Whether concerns are for mild or major NCD, behavioral health providers should
refer to and collaborate with neurology, neuropsychology, primary care, and other
specialty care when applicable, to fully understand the person’s context at the intersec-
tion of medical/neurological conditions and behavioral/emotional status and history. In
academic hospital or specialty clinic settings (e.g., physical medicine and rehabilitation,
geriatrics), team approaches are the standard of care. When events leading to decline
have been abrupt (e.g., stroke, traumatic brain injury), acute and subacute rehabilitative
services aim at the reacquisition of repertoires (Duncan et al., 2021). However, outside
of these settings medical follow-up for individuals with NCD tends to be insufficient as
NCDs are stigmatized (Scerri et al., 2023), and healthcare systems are unprepared to
conduct the observational detective work necessitated by unreliable self-reports that can
accompany cognitive decline (Frederiksen & Waldemar, 2021). Behavioral health
providers who detect or hear concerns about cognitive decline from their community-
dwelling clients must be prepared to become their advocates, coordination hubs, and in-
session problem-solvers for collaborative treatment planning across multiple providers
to improve quality of life in a fragmented healthcare system.

Psychiatric Conditions
Depression, anxiety, and apathy are most observed with NCD; indeed, withdrawal
from activities, general apprehension, and failure to initiate interactions can be
understood in the context of narrowing skills and repertoires; at the same time,
 Cognitive Loss 233

they also are a risk factor of progression from mild to major NCD (Ma, 2020). The
interventions discussed earlier are applicable to NCD comorbid with these
conditions.
Anecdotally, individuals with psychiatric treatment histories, particularly involun-
tary hospitalizations, and other interpersonal trauma histories may be more likely to
refuse services, interpret visuospatial disturbances as threatening, or engage in self-
protective behaviors. When past trauma-related responses have been well managed
during an individual’s lifetime, cognitive decline may lead to a concomitant decrease
in relevant coping and self-management skills, with a re-emergence of posttraumatic
fear responding. Currently, there are no assessment tools that assist with distinguish-
ing post-traumatic stress from other emotional and behavioral changes (Havermans
et al., 2022), and population prevalence data are not available (Sobczak et al., 2021).
Trauma-informed service protocols are emerging in geriatric settings (e.g., Cations
et al., 2021; Couzner et al., 2022), but current evidence for their effectiveness is
lacking. In general, as discussed throughout this chapter, the destigmatizing of
emotional and behavioral changes and the promotion of reassurance and safety
from interpersonal coercion are recommended.
Assessment should include the degree to which care partners may have longstand-
ing behavioral or physical health difficulties that might interfere with providing
instrumental assistance and warrant their referral to individual treatment; such comor-
bidities cannot be ignored, as they correlate with abuse and neglect of the person with
cognitive loss (Pillemer et al., 2016).

Demographics
While overall risk for NCD is declining, in the United States non-Hispanic Black
individuals are at a relatively greater risk of developing neurodegenerative diseases
than non-Hispanic White individuals (Power et al., 2021), with Hispanic White indi-
viduals also at greater risk than non-Hispanic White individuals (Manly et al., 2022),
and women at a greater risk than men. Such differences likely reflect differential risk
factors (systemic oppression, education, health literacy, socioeconomic status) in the
presence of health disparities (e.g., untreated hypertension, uncorrected sensory loss).
These disparities continue throughout the care trajectory. During the Covid-19 pan-
demic, Black men with NCD, for example, were more likely to be diagnosed with new-
onset schizophrenia and treated with sedatives than other resident populations in long-
term service settings (Cai et al., 2022). Thus, discriminatory behavior and misconduct
by providers are ongoing social justice concerns (Findley et al., 2023).
Sociocultural and familial systems differ in terms of expectations of autonomy
and reliance on family members for assistance, related expectations of family care,
demands on individual family members, attitudes toward third-party or residential
care, and resources. These aspects must be assessed on a case-by-case basis. Recent
234 Claudia Drossel

large-N, cross-cultural studies with adequate methodology and sampling suggest –

contrary to some earlier studies – that, in the United States, Black caregivers report
greater psychological well-being than White ones, potentially due to familial
expectations and availability of social support networks (Liu et al., 2021). When
working with members of LGBTQIA+ populations, whose communities rely on
mutual aid, distinct needs for advocacy and health trajectories may be identified and
addressed (Singleton & Enguidanos, 2022). Notably, many members of the cohort
with cognitive decline today lost friends and partners during the height of the AIDS
crisis and have significant histories of criminalization and stigmatization.
Suggestions as to how to deliver culturally humble and linguistically sensitive
interventions are emerging.
The availability of social and financial resources affects problem-solving, includ-
ing the readiness of spouses or family members to support the person with cognitive
loss (e.g., current employment status, past or current relationship strain) and the
availability of occasional respite or structured third-party assistance (e.g., long-term
care insurance, eligibility for social services). In the United States, age at diagnosis
may have a significant impact on the availability of services.

Medication
Nonpharmacological interventions are first line for behavioral and emotional
changes associated with cognitive loss (e.g., Meng et al., 2021; National Institute
for Health and Care Excellence, 2018). Yet, inappropriate medication use is high
with NCD (Maust et al., 2017), both in community-dwelling populations (Bae-
Shaaw et al., 2023) and in long-term service settings, where concerted efforts to
decrease psychotropic medications are ongoing (McDermid et al., 2023). At pre-
sent, central nervous system (CNS) depressants – none of which have an indicated
use for restlessness or confused and self-protective behavior (e.g., warding off staff
attempts to undress the person) – have been suggested only for short-term, emer-
gency administrations (Peisah et al., 2011), after acute medical conditions, pain,
adverse medication effects (Al Rihani et al., 2021), and social or other environmen-
tal factors have been ruled out and documented (Kales et al., 2019). Many healthcare
providers, residential care staff, and family members, upon reaching the limit of
their problem-solving abilities and when proximal “triggers” are not obvious, tend
to attribute behavioral and emotional problems to the inevitable effects of the
neurological disease and resort to the off-label prescription of sedating medications
(Ma et al., 2020). Emerging evidence (e.g., Anderson et al., 2014) suggests that the
presence of a specialist team can shift prescribing practices, even when behavioral
disturbances led to hospitalization. In a vulnerable population whose central ner-
vous system is already compromised by neurodegenerative processes, long-term use
of psychotropic medication with anticholinergic or CNS-depressant properties
 Cognitive Loss 235

Box 13.1 Format and Duration

Interventions for individuals with cognitive loss and their care partners are available
across a range of formats (bibliotherapy, computer-based interventions, in-person and
telehealth sessions, individual and group formats) with different durations. Selection
should be individualized, weighing whether a given format circumvents common
barriers to accessing services (e.g., lack of transportation or respite) and offers the
person opportunities for full engagement with treatment (e.g., quality of technology
and connectivity; provider’s ability to effectively observe and shape repertoires via
behavioral skills training). When neurocognitive disorders are degenerative, the person
with NCD and their family might need regular consultation for emotional and
behavioral changes as functional status shifts.

increases fatigue, confusion, and fall risk (Lippert et al., 2020), and hastens decline.
Thus, administration should be accompanied by systematic monitoring of whether
use interferes with orientation, goal-oriented behavior, and engagement in mean-
ingful activities.

Conclusion
Nonpharmacological interventions are first-line interventions for the emotional and
behavioral changes associated with cognitive loss. They represent a high-complexity
area of practice because of multiple etiologies, highly variable presentations, and the
level of comorbidities. Advanced competencies in behavioral science are needed to
successfully problem-solve, with individually tailored functional-analysis-based
interventions to promote client well-being. Interdisciplinary care coordination is
necessary to ensure that behavioral interventions are not applied to behavioral
changes that communicate pain or other acute medical events. At present, multi-
component interventions incorporate functional-analysis-based behavioral manage-
ment to varying degrees, and those that have removed functional analysis from their
protocols have failed to produce reliable outcomes.

Useful Resources

Books
• Bush, S. S., Allen, R. S., & Molinari, V. A. (2017). Ethical practice in geropsychology. APA
Books.
• Farmer, R. F., & Chapman, A. L. (2016). Behavioral interventions in cognitive therapy:
Practical guidance for putting theory into action (2nd ed.). APA Books.
236 Claudia Drossel

• Gaugler, J. E., & Kane, R. L. (Eds.). (2015). Family caregiving in the new normal. Academic
Press.
• Haynes, S. N., O’Brien, W. H., & Kaholokula, J. (2011). Behavioral assessment and case
formulation. John Wiley & Sons, Inc.
• Kitwood, T., & Brooker, D. (2019). Dementia reconsidered revisited: The person still comes
first (2nd ed.). McGraw-Hill Education (UK).
• McCurry, S., & Drossel, C. (2011). Treating dementia in context: A step-by-step guide to
working with individuals and families. APA Books.
• Miller, B. L., & Boeve, B. F. (Eds.). (2017). The behavioral neurology of dementia (2nd ed.).
Cambridge University Press.

Websites
• American Psychological Association caregiver briefcase: www.apa.org/pi/about/publications/
caregivers
• American Psychological Association Guidelines for the evaluation of dementia and age-related
cognitive change: www.apa.org/practice/guidelines
• Geropsychology resources: https://gerocentral.org

Systematic Review
• Gallagher, M., McLeod, H. J., & McMillan, T. M. (2019). A systematic review of recommended
modifications of CBT for people with cognitive impairments following brain injury.
Neuropsychological Rehabilitation, 29(1), 1–21. https://doi.org/10.1080/09602011
.2016.1258367

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 14
Antisocial Behavior
Devon L. L. Polaschek

Antisocial behavior is defined as behavior that violates common social mores or

legislation by infringing on the rights of others, or otherwise offending or harming
others (Skeem & Cooke, 2010). Antisocial personality disorder (AsPD) and conduct
disorder (CD) are diagnoses for people whose behavior is frequently, persistently, and
diversely antisocial (APA, 2022). Although many criminal behaviors contribute to
meeting the criteria for these diagnoses, so too do behaviors that may not be crimin-
ally sanctionable, but are commonly considered immoral, unethical, or negligent.
People whose pattern of antisocial behavior starts in adulthood may be diagnosed
with CD, but alternatively their presentation may be labeled adult antisocial behav-
ioral syndrome (AABS; Ehlers et al., 2022). CD is most often diagnosed in people
under the age of 18, and symptoms may emerge as early as the preschool years.
Regardless of age, CD requires “A repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms or rules are
violated, as manifested by the presence of at least three of . . . 15 criteria in the past 12
months . . . with at least one criterion present in the past 6 months” (APA, 2022,
p. 530). The criteria are organized into four categories: aggression to people and
animals, destruction of property, deceitfulness and theft, and serious violations of
rules; criteria from any category meet diagnostic requirements.
AsPD requires “a pervasive pattern of disregard for and violation of the rights of
others, occurring since age 15 years” (APA, 2022, p. 748). AsPD symptoms include
behavior that is grounds for arrest, deception or lying, impulsivity, irritability,
aggressiveness, recklessness or irresponsible behavior, or a failure to show remorse
for those harmed. Behaviors typifying evidence of AsPD vary widely in their
severity and criminality; a substantial proportion of those with AsPD may have
seldom or never broken the law, while others may have long conviction histories
(NCCMH, 2009).
Diagnostic criteria for AsPD have varied considerably over the evolving versions
of the Diagnostic and Statistical Manual of Mental Disorders (DSM), sometimes with
little overlap from one to the next (Cunningham & Reidy, 1998), in an effort to
246
 Antisocial Behavior 247

produce a reliable and valid way of capturing “criminal personality” (Gurley, 2009)
even though, in reality, the personalities of people involved in crime are diverse
(Blackburn, 1988). Since the DSM-III, reliance primarily on behavior as symptoms
has concealed heterogeneity in the underlying personality traits, because the same
behavior can result from diverse traits (Brazil et al., 2018). The picture is further
complicated by conflation in the text surrounding the criteria with a more serious and
rarer disorder, psychopathy, that is not included in the DSM. A minority of people
with AsPD meet criteria for psychopathy (Brazil et al., 2018). Psychopathy will not be
further covered in this chapter, but clinicians most often use one of the Hare
Psychopathy Checklist measures (e.g., the Psychopathy Checklist-Revised; Hare,
2003) to identify levels and components of psychopathy.
Lifetime prevalence estimates of AsPD in community samples range from 1% to
4%; the disorder is 3–5 times more common in men than in women (Werner et al.,
2015). People with antisocial behavior presenting mainly in adulthood (AABS, or
adult-onset CD) are much more numerous (Ehlers et al., 2022). On average, a quarter
to a half of male prisoners and about 20% of female prisoners have been diagnosed
with AsPD, depending on the institution and jurisdiction (Fazel & Danesh, 2002).
The relevance of these diagnoses to treatment varies substantially, depending on
the setting. Diagnosis is typically important in health settings. However, most treat-
ment for people with extended histories of antisocial behavior occurs in the criminal
justice system, where these diagnoses are often not used at all. Bringing together
health and justice knowledge of antisocial behavior to create the most informative
picture of how to approach psychotherapy is a major focus of this chapter.

Etiology and Theoretical Underpinnings of Treatment

In principle, diagnosis gathers together people whose difficulties share a common
etiology that guides treatment. But with its emphasis strongly on behavior, a diagnosis
of AsPD gathers together a heterogeneous group of people with regard to personality
traits and comorbidity; some have even suggested that, as a group, people with AsPD
have little in common other than their antisocial behavior (Cox et al., 2013).
Unpacking this heterogeneity into more homogeneous subtypes could lead to
a better understanding both of etiology and of treatment effectiveness (McKinley
et al., 2018). But, to date, subtyping research does not directly inform treatment.
Instead, the etiology of AsPD is typically discussed in very general terms that do
not reflect whether there are meaningful differences within the diagnosed population.
AsPD etiology is usually described as “biopsychosocial,” reflecting the contributions
of various domains of phenomena or experiences to clinical presentations (Glenn
et al., 2013). Furthermore, most studies of etiology have examined people with
a history of antisocial behavior, rather than specifically those who meet AsPD criteria,
248 Devon L. L. Polaschek

making the etiological relevance of meeting the diagnostic criteria difficult to

evaluate.
Biopsychosocial models bring together biological, psychological, and both social
and physical environmental factors (Thomson, 2019). About half of the variance in
antisocial behavior is attributed to heritable or genetic factors (Tuvblad, 2014),
including temperamental tendencies that facilitate rule breaking, and various subtle
neuropsychological deficits that may be evident in infancy (e.g., Moffitt, 2007).
Longitudinal studies have also identified a plethora of other psychological and
environmental factors that increase the risk of AsPD from conception and into
childhood, including prenatal maternal malnutrition or substance use, birth complica-
tions, maternal withdrawal, neglect, child abuse and maternal-partner-violence vic-
timization, erratic and punitive parental discipline, subtle neuropsychological deficits,
modeling and reinforcement for antisocial behavior, family poverty, and crime-
riddled neighborhoods (DeLisi et al., 2019; Farrington et al., 2017; Moffitt, 2007).
Two distinct paradigms guide the treatment of AsPD: medical or mental health
models, and correctional psychology. Each paradigm views etiology similarly, but
medical model approaches emphasize genetic and biological factors more (Brazil
et al., 2018; NCCMH, 2019) while correctional psychological approaches draw on
both criminological theories and longitudinal research on the development of anti-
social propensity, and so give somewhat less emphasis to genetics and biology (Bonta
& Andrews, 2016; Farrington, 2003).
The medical approach to treatment is not logically connected to the emphasis on
biological and genetic mechanisms in etiology; instead, it is “mainly rooted in
tradition” (i.e., generic psychiatric treatment traditions: psychotropic and psycho-
social; Bateman et al., 2015, p. 736). Drug treatment is not recommended due to a lack
of evidence of effectiveness but may be effective for comorbid disorders (Bateman
et al., 2015). Various schools of psychotherapy used with personality disorders in
general (e.g., dialectical behavior therapy, schema therapy, social problem-solving
therapy, psychodynamic and client-centered psychotherapy; van den Bosch et al.,
2018) have been used with AsPD.
The correctional psychology approach has eschewed medical diagnosis; treatment
reflects the severity of the person’s propensity for antisocial behavior, based on
estimates of their risk of future crime. The foci of treatment are psychological and
social characteristics that conceptually and empirically underpin that propensity:
the number, type, and extent of these “symptoms” (i.e., the dynamic risk factors).
Relevant theories and models of antisocial propensity explain the development and
maintenance of these presenting symptoms and how they contribute to antisocial and
criminal behavior. Treatment uses the most effective approaches to improving both
symptoms and behavior (i.e., reducing dynamic risk factors): social learning, behav-
ioral, and cognitive approaches (Bonta & Andrews, 2016). Although both medical
and correctional approaches primarily focus on psychological and environmental
 Antisocial Behavior 249

aspects of intervention, we cannot assume that biology or gene expression are thus
unaltered. Although treatment effects on these aspects are poorly understood and
seldom researched, psychosocial approaches may lead to alterations in these sub-
strates (Thomson, 2019).

Brief Overview of Treatments

Mental-health-based commentary on treatment currently concludes that, at best, there
is “little or no evidence of effective treatments” (van den Bosch et al., 2018, p. 72) for
adult patients with AsPD (Gibbon et al., 2020). Meta-analyses of treatments for
persistently antisocial adults outside of health settings tell a different story (Lipsey
et al., 2007), meaning that this section and the next are informed largely by research
and treatment with people in the criminal justice system. Cognitive-behavioral
approaches have the strongest empirical support for effectiveness (e.g., Lipsey
et al., 2007; Smith et al., 2009). The following paragraphs present three representative
examples of “branded” programs under this umbrella.
First, developed in the mid-eighties, Reasoning and Rehabilitation (R&R; Ross
et al., 1988) aims to remediate widespread cognitive skill deficits associated with
antisocial behavior (Robinson & Porporino, 2004). It focuses primarily on cognitive
skills, including meta-cognition (e.g., reflecting on how people think informs what
they think and do) and self-control (e.g., stopping to consider consequences before
acting), critical reasoning, and developing better values to live by (e.g., appreciating
other people’s values, attitudes, and needs). It is provided in structured small group
discussion format and has been widely used internationally with people in the
criminal justice system. A narrative review and meta-analysis of 16 evaluations –
26 separate comparisons – from 4 countries found that R&R completion was associ-
ated with an average 14% decrease in the likelihood of reconviction (Tong &
Farrington, 2006). The evaluation designs were typical of those used to determine
intervention effectiveness with offender rehabilitation programs; a mix of randomized
controlled trials and quasi-experimental evaluations compared samples of R&R
attendees with untreated control samples (Tong & Farrington, 2006).
Second, alongside evidence of skill deficits in how people think, there is also
substantial research evidence of an association between what people think – referred
to by various terms (e.g., attitudes, beliefs, values, thinking errors, moral judgments,
cognitive distortions, dysfunctional automatic thoughts) – and antisocial or criminal
behavior (Helmond et al., 2015). Cognitive self-change (CSC; Bush et al., 2016) is an
example of a small group intervention that focuses on “thinking reports,” in which
each participant learns to observe and report on the content of their own specific
thoughts during recent incidents. As this skill develops, they identify habitual patterns
of thinking that help to generate or support criminal and violent acts, and learn how to
intervene to challenge these patterns. Ultimately, summaries of the thinking habits
250 Devon L. L. Polaschek

they have identified become the basis for a plan for maintaining changes in their new
thinking skills in the face of routine life challenges. Other intervention elements
support CSC provision, including supportive authority by group leaders, and an
emphasis on participant autonomy and choice (see Bush et al., 2016). A study of
incarcerated people in Vermont compared CSC participants with a control group of
similar incarcerated people who were not offered the program. Although the sample
sizes were small, the results suggested that undertaking CSC led to reduced recidivism
risk; 50% of CSC attendees and 71% of controls were charged with a new crime in the
community in the two years following release from prison (Henning & Frueh, 1996).
Third, aggression replacement training (ART; Goldstein & Glick, 1987) was primar-
ily developed for youth, but also used with adults. ART is directed toward theorized
deficits in prosocial skills, resulting from a developmental environment in which such
skills were not modeled or reinforced, in young people who instead develop an
extensive antisocial and aggressive behavior repertoire. There is evidence that young
people with CD may lack some of these skills: for example, poor social problem-solving
and peer relationship skills (Dodge, 1993), and difficulties with cognitive and affective
perspective taking (Anastassiou-Hadjicharalambous & Warden, 2008).
ART has three main components: (a) skillstreaming, comprising a curriculum of
skills training for 50 prosocial behaviors; (b) anger control; and (c) moral reasoning
training. ART has been widely used across all ages, and its efficacy in increasing
prosocial behavior and reducing recidivism in young people has been demonstrated
(Goldstein & Glick, 1994), its effectiveness has not yet been adequately researched
with adults (Brännström et al., 2016).
In practice, branded treatment packages like these represent only a small proportion
of the treatment programs offered to people with problematic levels of antisocial
behavior. Most are not “branded”; they are constructed following a more general
approach that is outlined in the next section, and are mainly delivered in adult
correctional or juvenile justice settings.
The relevance of this work to the treatment of antisocial behavior in health settings
has been somewhat overlooked, in part due to the “nontraditional” treatment settings
(e.g., prisons), but perhaps also because the diagnosis of AsPD is seldom assigned in
these contexts, and success is most often measured in terms of reduced likelihood of
reconviction, rather than symptom change.
Since the 1980s, a large number of meta-analyses have examined the effectiveness
of diverse interventions for antisocial behavior; McGuire (2013) listed 100 more than
a decade ago. Among these, psychological treatment programs that are described as
cognitive-behavioral, behavioral, or otherwise based on cognitive social learning
theory (Bandura, 1986) are associated with the strongest effect sizes on average
(Bonta & Andrews, 2016; Lipsey et al., 2007; Pearson et al., 2002; Wilson et al.,
2005). These meta-analyses report results for both RCTs and quasi-experimental
evaluations (QEEs; i.e., designs pairing statistically matched treatment and untreated
 Antisocial Behavior 251

samples), with the latter typically constituting the majority of individual studies.
Although RCTs are in principle methodologically stronger, myriad factors can com-
promise the “gold standard” RCT design (Polaschek, 2019b), and effect sizes for
RCTs and higher-quality QEEs are often similar (Gannon et al., 2019; see also Lipsey
et al., 2007; Mackenzie & Farrington, 2015), justifying the expanded number of
studies. Overall, although there is considerable heterogeneity of effect sizes for
these cognitive and behavioral psychological treatment programs, recidivism rates
are typically lower for the treatment conditions compared to controls (see Lipsey
et al., 2007, fig. 1), whether RCTs or QEEs. Wilson et al., (2005) reported a mean
effect size of 0.51 (based on standardized mean differences in the proportion of
recidivists in treatment vs. control conditions). By contrast, the mean effect size for
the Lipsey et al. (2007) meta-analysis was an odds ratio of 1.53; approximately
equivalent to 40% of controls and 30% of treated individuals recidivating in the
12 months after intervention. These meta-analyses also confirm that treatments that
are effective with antisocial behavior come from a relatively small segment of the
array of psychotherapies used with psychological disorders. Although the correctional
treatment field is now dominated by a variety of cognitive and behavioral interven-
tions, older research confirms that approaches popular for other presenting problems
are not effective (e.g., client-centered psychotherapy, psychodynamic psychotherapy;
Andrews et al., 1990; Garrett, 1985).
Health research based only on evaluations of the (in)effectiveness of these more
common generic approaches to mental health treatment (e.g., client-centered psycho-
therapy, psychodynamic psychotherapy; van den Bosch et al., 2018), or that use only
RCTs to determine treatment effectiveness (Gibbon et al., 2020), and include studies of
treatment participants only if they have been assessed as having AsPD, can, in combin-
ation, lead to erroneous conclusions about the treatment of antisocial behavior, including
that little is known about “what works” – or, worse, that “nothing works.” Correctional
treatment is no miracle solution to the lack of well-constructed or well-informed health
treatments for antisocial behavior, but accumulating empirical research has supported
the promulgation over 20 years of a consistent series of principles to guide the
development and delivery of interventions (e.g., Bonta & Andrews, 2016; Bourgon
et al., 2009; Gendreau & Smith, 2012; McGuire, 2013). More recently, some of these
practice guidelines are filtering through into health settings (e.g., NCCMH, 2009), albeit
that there is still considerable work to do in these settings to ensure that they are adapted
to provide the best possible service for people with antisocial behavior disorders.

Credible Components of Treatments

Scientifically credible interventions link intervention design and delivery to
plausible theories of etiology, and target empirically supported change mechan-
isms using empirically supported change methods. They are successful in
252 Devon L. L. Polaschek

achieving symptom reduction during treatment, and beyond the end of the
intervention (Hecht et al., 2018). Effective interventions for criminal behavior
typically are intensive and multimodal; they target multiple features using a range
of methods. And they target this extensive input at those most at risk, recognizing
that here is where the most real-world impact can be achieved, but only with
considerable effort. Treatment processes attend closely to common characteristics
of the treatment population, and the context of treatment is also important.
Treatment content, process, and context are described in Box 14.1, drawing
from the empirical and theoretical literature on what works with criminal behav-
ior (e.g., Craig et al., 2013; Latessa et al., 2020), and from the Risk-Need-
Responsivity (RNR) model (Bonta & Andrews, 2016).

Developing Treatment Readiness

Readiness is enhanced by gently nudging clients toward seeing their antisocial behavior
as their responsibility, as harmful, or even as problematic to their own goals. Cognitive
techniques for exposing antisocial thinking (e.g., CSC) are used here. A detailed map of
a recent offense process – the person’s cognitive, affective and behavioral steps in the
build-up, enactment, and post-offense consequences – is also useful for exposing and
for reflection on ingrained habits of thinking, reacting, and acting that become the focus
of later treatment. In group treatment, therapists often observe that other members may
be more effective than themselves in helping to draw out the details, possibly because
their perspectives are more highly valued by other group members (Wetzelaer et al.,
2014). The approach is collaborative rather than aggressively confrontational (Bonta &
Andrews, 2016); often, these ways of thinking and behaving have been functional at
some point in the person’s life, but when triggered in adulthood, they facilitate
antisocial behavior (e.g., Early Maladaptive Schemas; Bernstein et al., 2007).
Understanding how they developed from adverse childhood experiences can help to
reduce defensiveness and promote motivation to change.

Learning Key Skills

Once the referred person begins to recognize that their offenses don’t occur “out of the
blue,” they can identify which of their treatment needs (i.e., “symptoms”) they are
prepared to work on, leading into the second major content phase. Here, a variety of
skills directly target common dynamic risk factors (DRFs): the “symptoms.” DRFs
are putatively changeable characteristics that are empirical correlates of crime (Olver
et al., 2014). Besides antisocial beliefs, attitudes, and values, common targets for
improvement or change include an irritable, aggressive, impulsively reactive tem-
perament, a preference for spending time with antisocial rather than prosocial peers,
 Antisocial Behavior 253

Box 14.1 Treatment Process

Clients with antisocial behavior seldom come to treatment recognizing the need for
change, or having the capabilities to effect it; they may be treatment resistant
(Derefinko & Widiger, 2016). The residue of childhood trauma, traumatic brain
injuries, drug and alcohol use, unstable living and working circumstances, extreme
views of personal autonomy, a self-focused view of the world, attentional difficulties,
physical restlessness, illiteracy, learning difficulties and other comorbidities (see
“Other Variables Influencing Treatment” ) needs to be accommodated for effective
treatment. Accordingly, therapists socialize clients into the treatment process,
motivate them to engage, and minimize barriers to client change. Neither
psychoeducation nor insight-development therapy leads clients through what
“behaving better” (i.e., more skillfully) looks and feels like; it is action-oriented, well
scaffolded, and repetitive.
Often, two collaborative and supportive therapists lead a group of 8–12 clients.
Group formats are preferred because antisocial behavior is often social behavior
(Hollin, 2010). In groups, people’s dysfunctional and self-focused patterns of
thinking and behaving emerge during interaction with other group members’ own
treatment participation. Group members, as peers, also provide a more
ecologically valid and credible audience with whom to try out ideas and practice
skills.
Therapists need a well-developed manual, expert therapy skills, familiarity with
antisocial clients and regular clinical supervision. Monitoring treatment fidelity – the
extent to which the treatment adheres to the manual – is vital. Therapy can fail, or even
enhance antisociality if therapists cannot establish a prosocial group environment, or
drift away from treatment-as-designed.
Treatment also needs to be intensive, whether group-based, individual, or both.
Group treatments of between 150 and 300 hours are recommended, reflecting clients’
challenges in weakening entrenched habits by learning new skills whose effectiveness
they may doubt. Little research informs whether recidivism outcomes or symptom
changes are greater in one format over another (Gannon et al., 2019; Looman et al.,
2014).
Health professionals’ training seldom prepares them for working with antisocial
clients. Effective therapists have a passion for the challenges of this type of clinical
practice, and find it rewarding. They work hard to facilitate effective client alliances, and
interact with warmth and humor, but also use a firm but fair (authoritative not
authoritarian) manner. Once developed, they use the relationship to influence the
client toward positive change, ignoring or occasionally disapproving of antisocial or
negative behavior (Bonta & Andrews, 2016). Effective therapists use social learning
principles such as modeling, supporting imitation, and shaping approximations of
desired behavior through practice and contingent use of praise (Palmer, 2019; Wilson
et al., 2005).
254 Devon L. L. Polaschek

substance abuse, poor quality interpersonal relationships, and an underdeveloped

work ethic (Bonta & Andrews, 2016). Treatment focuses on actively modeling,
rehearsing, and reinforcing concrete skills that provide alternatives to antisocial
solutions (e.g., prosocial thinking; problem-solving; managing volatile emotional
reactivity and substance use; and prosocial relationships, communication, and conflict
resolution; Polaschek, 2019a).

Preparing for Posttreatment Life

The last phase of treatment concentrates on consolidating and generalizing
changes, and planning for posttreatment living, which typically includes develop-
ing prosocial capital and putting in place lifestyle elements that support more
prosocial behavior (e.g., where one lives and works, who one socializes with),
and identifying likely scenarios for failure and strategies to mitigate these high-
risk situations (e.g., recognizing precursors early, seeking help from social sup-
ports, turning down risky opportunities; known as relapse prevention). The
quality of release plans and relapse prevention have each been shown to lead to
improved outcomes with respect to recidivism (Dickson et al., 2013; Dowden
et al., 2003).

Treatment Context
The remaining important component of effective treatment is the context in which
it occurs, and the processes in place for maintenance after treatment finishes. If
antisocial behavior is often social behavior, then the social environment around
treatment is also essential to success; the people around the treatment participant –
whether institutional staff or family and friends – need to be supportive of change.
Therapeutic communities are one option for institutional treatment that can
achieve this support. In community-based treatment, this means involving pro-
social family in aspects of the intervention in order to enhance the likelihood that
they will support the client’s positive changes, and to balance potential sources of
reinforcement for antisocial behavior. Antisocial peers, which can include family
members, are a major risk factor for ongoing antisocial behavior (Olver et al.,
2014). Also desirable is for treatment to be followed by ongoing professional
support to help with linking the person to other services (e.g., housing, employ-
ment, financial management, parenting) that will address associated issues, and to
help with troubleshooting around future incidents of antisocial behavior, or prob-
lems that increase the likelihood of reverting to old habits. In correctional psych-
ology this aspect is often referred to as reintegration, or supporting desistance
(Polaschek, 2019a).
 Antisocial Behavior 255

Approaches for Youth

Disruptive behavior or disordered conduct in childhood is also heterogeneous in
presentation and etiology (Kazdin, 2015) but there is much more research
informing treatment. Effective treatments strive to intervene with multiple fac-
tors from child, family, school, and neighborhood domains (Boxmeyer et al.,
2018). Effective approaches for children under 12 years old have been identified
in an evidence review using rigorous criteria to allocate 64 studies into “well
established,” “probably efficacious,” “possibly efficacious,” or “experimental”
categories (Kaminski & Claussen, 2017). The authors concluded that parent-
focused behavior therapy, whether individually or in groups, and including
behavioral elements, was empirically well established (Kaminski & Claussen,
2017).
Using a similar approach to Kaminski and Claussen (2017), McCart et al.
(2023) identified some treatments that have strong research support for ado-
lescents already in contact with the criminal justice system, but less so for
young people who are not. That is, all of the well-established treatments were
targeted for youth involved in the juvenile justice system. They included
multisystemic therapy, functional family therapy, and treatment foster care
(McCart et al., 2023). The next level down – “probably efficacious” – also
included interventions for youth with disruptive behavior disorders outside the
criminal justice system. The most compelling evidence of effectiveness in this
category was for combined therapies from two or more theoretical orienta-
tions: typically, cognitive-behavioral with another, such as family therapy or
attachment therapy (McCart et al., 2023). Research on children with high
callous-unemotional traits – a more severe subtype of disruptive behavior
disorder – has been particularly prominent in recent years. Although callous-
unemotional traits may predict poorer treatment outcome overall, promising
interventions may be emerging (Polaschek & Skeem, 2018). Parent–child
interaction therapy, modified to increase warm and responsive parenting,
reward-based parenting, and parental coaching and reinforcement of children’s
emotional skills, was provided to the parents of 3–6-year-old children with
callous-unemotional traits and conduct problems. The intervention was associ-
ated with large effects on parent-rated conduct problems, callous-unemotional
traits and empathy, and observer-rated compliance at the end of treatment, and
these changes persisted through three months of posttreatment follow-up
(Kimonis et al., 2019). A recent RCT of 159 adolescents given either func-
tional family therapy or a control intervention resulted in improvements in
aggressive behavior, social skills, family cohesion, and youth-rated material
support, even though callous-unemotional traits themselves did not appreciably
reduce (Thøgersen et al., 2022).
256 Devon L. L. Polaschek

Other Variables Influencing Treatment

Assessment and Diagnosis
The assessment of AsPD in health settings should use a purpose-designed instrument
such as the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-
5-PD; First et al., 2016) though there are no established ways of judging severity on this
basis, and it remains unclear whether applying dichotomously a diagnosis of AsPD is
relevant to treatment outcomes for people with antisocial behavior. In correctional
settings, assessment processes center around validated tools for assessing both the
level of risk of the person committing further criminal offenses and their most relevant
treatment targets for reducing risk (e.g., the Level of Supervision Inventory; Andrews
et al., [2004]; the Violence Risk Scale; Wong & Gordon, [2006]), termed DRFs.
Severity can then be judged by the number and extent to which DRFs are present,
which then informs both treatment intensity and focus. Assessment of antisocial
behavior problems ideally includes both client interview and interviews with key
informants (e.g., residential staff, family members).

Comorbidity
Comorbidity is common in people with antisocial behavior histories. Those with
AsPD, for instance, may show elevated prevalence of many other types of mental
disorder, with comorbidity being the norm rather than the exception. Substance abuse
disorders, anxiety, depression, and borderline personality disorder are the most
common (Glenn et al., 2013; NCCMH, 2009). Although in health settings antisocial
behavior leads to concern about the treatment of comorbidity and the rejection of
AsPD clients from comorbid treatment (NCCMH, 2009), equally comorbidity may
affect treatment progress directed at antisocial behavior change (Glenn et al., 2013).
Antisocial behavior is also associated with a host of negative life circumstances and
outcomes across mental and physical health, economic success, and lifestyle stability.
The Dunedin longitudinal study showed that at age 32, along with increased rates of
anxiety, depression, post-traumatic stress, alcohol and drug dependence, and suicide
attempts, men and women with early-onset and longstanding antisocial behavior also
were in significantly poorer physical health (lung functioning, gum disease, serious
injury, cardiovascular functioning) than multiple comparison groups, including one
whose antisocial behavior began in adolescence and another of low-antisocial people
(Odgers et al., 2008). Economically, this same antisocial group had lower incomes,
more were unemployed and had no qualifications, and more lacked money for
necessities (Odgers et al., 2008). Finally, people with AsPD are more likely to
experience almost all forms of premature death (Krasnova et al., 2019). Associated
features confirm that people with AsPD would benefit from help or intervention
across multiple lifestyle areas.
 Antisocial Behavior 257

Demographics
In western countries, AsPD is diagnosed in about 3% of the population; about 75% of
those diagnosed are men. Few studies have examined ethnicity or race; in the US,
Ehlers et al., (2022) found no differences between African, European, or Indigenous
Americans, but this is clearly an area that needs more investigation, especially given
wide disparities between European, non-European, and Indigenous imprisonment
rates in several western nations (e.g., Canada, US, UK, Australia, NZ).

Medication
To date, trials of various medications suggest that that medication is neither helpful
nor harmful in ameliorating antisocial behavior. A recent Cochrane Review (Khalifa
et al., 2020) reported results for people with AsPD from four RCTs; all relevant
participants were in study samples for reasons other than AsPD (e.g., substance use
problems). The studies compared a placebo condition with an antiepileptic drug
(phenytoin), desipramine, nortripyline (both antidepressants), and bromocriptine (a
dopamine agonist that caused severe side effects). The reviewers found that no
conclusions could be drawn, based on the poor methodological standards, general
lack of studies, and failure to measure relevant outcomes, including reconviction.
Overall, there also appears to be little rationale for how a particular class of drugs
might be effective in reducing presenting features of AsPD. The most popular idea is
that abnormalities in the serotonergic system that may cause impulsive aggressive
behavior – a features of some people with AsPD – may respond to antidepressants,
while others have suggested that drugs that are effective with underregulated behav-
ior, such as anticonvulsants, may also be useful. By contrast, another recent review
(Sesso & Masi, 2023) advocated for overcoming the limitations of the Khalifa review
findings by “including all meaningful sources of evidence that may provide relevant
details for a better definition of effective therapeutic strategies” (p. 184), but still came
up with very few studies, even when focusing on RCTs for pharmacological treatment
of potentially related conditions such as impulsive aggression. Sesso and Masi (2023)
noted that better definitions of the aspects of AsPD (e.g., aggression or mood
instability) being targeted were needed to advance pharmacological research, noting
the poor quality and outdated nature of the extant research. They concluded that the
treatment of first choice remans psychotherapy.

Conclusion
The development of effective interventions for adult antisocial behavior in health
settings remains mired in the limitations of current relevant diagnoses. AsPD and
CD diagnoses have no clear etiology, and tautologically specify symptoms that
largely comprise the behavior associated with having these purported mental
258 Devon L. L. Polaschek

disorders. In health settings, AsPD has then been used to exclude people from
treatment for other mental disorders, and failed attempts to use generic mental
health treatments for reducing antisocial behavior has led some health professionals
to conclude that “nothing works.”
Parallel developments in correctional psychology interventions offer promise that
is still to be fully capitalized on in health settings. But they also have significant
limitations in filling the needs of health practitioners. Correctional settings differ in
important ways from health settings. Those referred for correctional treatment may
also differ from the referral population in a health setting, where extensive criminal
convictions may not be inevitable. The focus on identifying effectiveness by reducing
reconviction risk is only indirectly related to the more immediate need to focus on
change in symptoms. Conceiving of symptoms as DRFs is useful, but correctional
treatment outcome studies mainly need to meet accountability requirements for policy
makers and politicians, to reduce recidivism. Consequently, the meaningful measure-
ment of change within treatment is underdeveloped and not always successful
(Polaschek, 2017). Also unclear are the most effective ways to work across cultures.
Although people from diverse ethnicities may also benefit from conventional western
psychology-based treatment approaches (Usher & Stewart, 2014) in some correc-
tional settings, Indigenous treatment approaches or hybrids incorporating equally
diverse cultural frameworks are under development and show early promise
(Gutierrez et al., 2018). Finally, correctional treatment is predominantly effective
when provided by cognitive-behaviorally trained psychologists or those trained by
them (Bonta & Andrews, 2016; Gannon et al., 2019). That leaves unaddressed how
those with other professional orientations can effectively contribute to treatment.
The UK NICE guidelines (NCCMH, 2009) begin the process of bringing together
these two separate areas of practice; doing so may offer benefits for both fields.
Perhaps the development of effective person-based approaches to treatment (e.g.,
treating a person’s anxiety, substance abuse, and antisocial propensity together) may
result from this union. The most pressing research area with regard to effective
treatment is how best to approach those whose antisocial behavior largely excludes
criminal convictions.
With empirically supported treatments, people with histories of persistent criminal
behavior may be able to exit the criminal justice system more rapidly than they
otherwise would. But with rare exceptions (see Coupland & Olver, 2020), treatment
studies have not examined long-term functioning other than recidivism, due to the
formidable challenges of follow-up studies. Future research should attend to this
important question.
Even without treatment, the long-term prognosis for people with AsPD is cau-
tiously positive. Longitudinal research suggests that much fewer people who met
AsPD diagnostic criteria as young adults continue to do so later in adulthood (Black
et al., 1995; Mulder et al., 1994). Research tracking people over decades shows that
 Antisocial Behavior 259

those involved in antisocial behavior when young do show steady, if slow, improve-
ments in life functioning, reduced involvement in crime, and less engagement with the
criminal justice system (Farrington et al., 2009; Laub & Sampson, 2003). Future
research needs to examine whether the underlying personality characteristics have
also improved.

Useful Resources

• The best example of integration between the health and criminal justice research literatures
reviewed here is the NICE guidelines: Antisocial Personality Disorder: The NICE Guideline on
Treatment Management and Prevention.
• For a succinct summary of the RNR model, see www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rsk-
nd-rspnsvty/index-en.aspx
• For a series of slides on “what works” for criminal behavior, see, see www.bscc.ca.gov/wp-
content/uploads/Principles-of-Effective-Interventions.pdf
• For those doing individual therapy Tafrate, R. C., & Mitchell, D. (2014). Forensic CBT:
A handbook of clinical practice. Wiley.

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 15
Borderline Personality and Other Personality Disorders
Joel Paris

Personality disorder (PD) is defined in the Diagnostic and Statistical Manual

(DSM-5-TR; American Psychiatric Association, 2022) as an enduring pattern of
inner experience and behavior, manifested in at least two of the following areas:
cognition, affectivity, interpersonal functioning, and impulse control. PDs begin
in youth and lead to difficulties in multiple contexts (work and relationships)
over many years. In this way, PDs differ from diagnoses such as major depres-
sive disorder in being a life-course pattern rather than an episode. The idea that
PDs should not be diagnosed before adulthood is mistaken: an early onset of
borderline personality disorder, usually in adolescence, has been confirmed by
a large body of research (Chanen & McCutcheon, 2013; Sharp & Tackett, 2014).
(Note: this chapter will use the convention of abbreviating PD when discussing
general personality disorder and will write out any specific personality disorder
that is mentioned.)
It is also important to note that most of the research on PDs, particularly as
related to psychotherapy, has been on the borderline category. The idea that
patients with a PD always require long courses of therapy has little research
support. This idea is based on the assumption that symptoms present for a long
time must require a lengthy therapy. However, there is little evidential support
for that conclusion. In fact, long-term therapy for any diagnostic entity has not
been well researched. Most of the research literature in psychotherapy concerns
treatments that last no more than six months, and virtually all outcome studies
concern therapies that last for a few months, or a year at most (Markham et al.,
2021).
In spite of a lack of evidence, the history of PD treatment has been marked by
advocacy for lengthy courses of therapy. Open-ended treatments, as opposed to time-
limited therapies, are likely to be chosen by therapists trained in psychodynamic
methods (Paris, 2019). Open-ended therapy has long been known to be associated
with large drop-out rates (Skodol et al., 1983), and its efficacy has not been evaluated
in randomized controlled trials (RCTs).
265
266 Joel Paris

The absence of research on extended courses of therapy reflects the clinical reality
that, in practice, most psychotherapies are brief, since longer treatments tend to be
expensive and inaccessible. Yet well-targeted interventions can have rapid effects on
symptoms, and many patients with borderline personality disorder who have had
symptoms for years can be treated effectively within a few months (Blum & Black,
2020; Laporte et al., 2018).
The impact of therapy needs to be framed by the life course of patients. Borderline
personality disorder typically begins in adolescence or early youth, and then gradually
improves with time, usually remitting by age 30 or 40 (Paris, 2020; Zanarini, 2019).
Instead of continuing therapy for years, treatment programs should set the goal of
hastening recovery.
The situation is now changing. A number of innovative methods of treatment have
been developed for borderline personality disorder, and clinicians have several
choices of methods (Choi-Kain, 2020). However, the situation for other categories
of PD is less encouraging – hardly any research has been carried out on these
disorders, so there is little to choose from.

Etiology and Theoretical Underpinnings of Treatment

Personality disorders are complex forms of psychopathology that have a complex
etiology. The best model is to frame PDs as the product of gene–environment
interactions, as exemplified by a biopsychosocial model (Engel, 1980). Linehan
(1993) applied a similar approach to the borderline category: a biosocial model
that hypothesizes interactions between heritable traits of emotion dysregulation
and an invalidating environment. The idea that borderline personality disorder is
mainly due to childhood trauma is mistaken, although it is true that early adversi-
ties of that nature tend to make the disorder more severe (Yuan et al., 2023).
PDs as a whole can most usefully be understood as exaggerations of personality
trait variations that have become extreme and dysfunctional. The most researched
system for describing these traits is the Five Factor Model (Widiger & Costa, 2013).
That is, patients with PDs tend to have higher amounts of: (1) negative affectivity,
(2) detachment, (3) antagonism, (4) disinhibition, and/or (5) psychoticism. These
five maladaptive traits fall on the opposite end of a continuum with more adaptive
traits (i.e., emotional stability, extraversion, agreeableness, conscientiousness, and
lucidity).
These relationships between disorders and traits offer some guidance for setting
treatment goals. Thus, for example, patients with PDs are generally high in
neuroticism but low in agreeableness and conscientiousness. This suggests that
they can benefit from skills in handling emotions, in developing more persistence
in the pursuit of life goals, and in managing relationships in ways that make them
work.
 Borderline Personality and Other Disorders 267

Brief Overview of Treatments

Borderline personality disorder is marked by long-term problems in emotion regu-
lation, interpersonal relationships, and impulsivity. Psychotherapy is the backbone
of treatment for this disorder. Over the last 30 years, well-designed clinical trials
have been conducted on several methods designed to treat borderline personality
disorder. The results generally show that tailored and structured forms of therapy
yield superior results when compared to treatment as usual. However, accessibility
of these expensive therapies is problematic, and more research is needed on ways to
shorten treatment (Paris, 2015, 2020).

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is an adaptation of cognitive-behavioral therapy
(CBT) combined with interventions drawn from other approaches (Linehan, 1993).
The method is specifically designed to target the emotion dysregulation (mood
instability) that characterizes borderline personality disorder, and to reduce impulsive
behaviors that accompany that dysregulation (Crowell et al., 2009). It applies chain
analysis to incidents leading to self-injury and overdoses, encouraging patients to
describe the emotions that lead up to impulsive behaviors. Therapy then teaches
patients alternative ways of handling dysphoric emotions. DBT also emphasizes
empathic responses to distress that provide validation for the inner experience of
patients with borderline personality. The program consists of individual and group
psychoeducation, as well as telephone availability for coaching.
DBT was the first psychological treatment for borderline personality disorder to be
tested in an RCT (Linehan et al., 1993). Its efficacy has since been replicated in studies
conducted by the original research group (Linehan et al., 2006), as well as by others
(Levy et al., 2018). The level of evidence for the efficacy of borderline personality
disorder has been rated as strong by the Society for Clinical Psychology (SCP, n.d.a.).
The first trial (Linehan et al., 1993) compared one year of DBT to treatment as usual
(TAU), and found DBT to be clearly superior, especially in regard to reductions in
self-harm, overdosing, and hospitalization. A second clinical trial (Linehan et al.,
2006) used a comparison group of “treatment by community experts” – therapists in
practice who identified themselves as interested in borderline personality disorder,
and whose fees were paid by the research team. The results again favored DBT, with
reductions in overdoses and subsequent hospitalizations within a year, although this
time there were no differences in reduction of self-harm. Replication studies in other
centers have produced similarly encouraging results, as confirmed by a Cochrane
Report (Storebo et al., 2020). These findings indicate that DBT is an effective and
specific method that is usually superior to traditional ways of treating patients with
borderline personality disorder.
268 Joel Paris

There are unanswered questions about DBT. While the original cohort received
therapy 20 years ago, they were never followed up for more than a year, so we do not
know whether treated patients maintained their gains and/or continued to improve.
Also, given the resources required to offer DBT in its original form for at least a year,
this form of therapy is not widely available.
DBT needs to be dismantled and/or streamlined for greater clinical impact (Paris,
2015). One report found that a 6-month version of DBT can be effective (Stanley
et al., 2007), and a larger study found 6 months of DBT to be as efficacious as a 12-
month course (McMain et al., 2022). DBT can probably be further shortened, as
shown by an effectiveness study that reported a good symptomatic response following
a 12-week course of therapy (Laporte et al., 2018).
While the most extensive body of research concerns DBT, it is unclear whether it is
a uniquely efficacious treatment, or whether other well-structured approaches yield
much the same results in borderline personality disorder. To address this issue,
McMain et al. (2009) administered DBT for one year, with the comparison condition
being another program developed specifically for borderline personality disorder:
general psychiatric management.

General Psychiatric Management

General Psychiatric Management (GPM) is an alternative method based on
American Psychiatric Association guidelines for the treatment of borderline per-
sonality disorder (Oldham et al., 2001), and has been manualized (Choi-Kain,
2020). The results of a comparative trial between DBT and GPM found no
differences between groups in terms of suicidality, hospitalization, or self-harm
(McMain et al., 2009), and both groups were doing well two years later (McMain
et al., 2012). These findings have important clinical implications, suggesting that
while DBT is often better than TAU, it can be matched by other therapies that are
designed for this population.

Systems Training for Emotional Predictability and Problem Solving

Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Blum
et al., 2008) is a program whose theory and practice closely resemble DBT. Focusing
on emotional dysregulation, it offers a brief intervention conducted in groups.
STEPPS is designed to supplement standard therapies, and it is therefore particularly
suitable for regions where specialized treatment is not available. The method has been
subject to a successful clinical trial (Blum et al., 2008) and independent replication
(Bos et al., 2010). STEPPS offers an alternative to the lengthy and expensive methods
of DBT.
 Borderline Personality and Other Disorders 269

Other Treatment Options

In addition to DBT, the Society of Clinical Psychology also lists two treatments for
borderline personality disorder that can be viewed as a hybrid between CBT and
psychodynamic therapy. First, mentalization-based therapy (MBT; Bateman &
Fonagy, 2006) is derived from the concept that patients need to be taught to “menta-
lize” (i.e., to accurately observe their own feelings and those of others). As in DBT,
patients are taught to recognize their emotions, to learn how to tolerate them, and to
manage them in more adaptive ways. Second, schema-focused therapy (SFT; Young,
1999) aims to modify maladaptive schemas deriving from adverse experiences in
childhood. However, access to SFT is not easy, especially given that it is designed to
last for three years. The level of evidence for both of these hybrid approaches has been
rated as moderate by the Society for Clinical Psychology (SCP, n.d.a.), and so they
will not be discussed further.
Transference-focused psychotherapy (TFP) is a modification of psycho-
dynamic treatment that aims to correct distortions in the patient’s perception
of the therapist during sessions (Clarkin et al., 2007). It differs from DBT and
MBT by placing emphasis on correcting transference phenomena, with the aim
of generalizing these observations to outside relationships. The level of evidence
for its efficacy has been rated as strong/controversial by the Society for Clinical
Psychology (SCP; n.d.a.). The controversial categorization was provided because
of the mixed results from RCTs, and so this treatment will not be discussed
further.

Credible Components of Treatments

If therapies based on so many different theories, and using very different techniques,
can produce the same results, might they have something in common? The findings
reviewed here show that structured therapies of any kind are most likely to be
successful for patients with borderline personality disorder. Traditional therapies
may have been less effective because they rely on unstructured methods that leave
patients who struggle with chaotic emotions adrift.

Common Factors
The treatments described earlier all have some evidence for their efficacy. They may
target different aspects of borderline personality disorder, yet the failure of com-
parative trials to find differences in outcome suggests that common factors must be
of crucial importance (Wampold & Imel, 2015). The most important common
factors in any therapy are a strong working alliance, empathy, and a practical,
problem-solving approach (Markham et al., 2021).
270 Joel Paris

In a complex disorder like borderline personality disorder, psychotherapy needs to

maximize these common factors and to make them more specific. The best-validated
methods offer a defined structure, focus on the regulation of emotions, and encourage
the solution of interpersonal problems through self-observation. Moreover, structure
is an essential element of treatment for patients with borderline personality disorder,
who often lead unstable lives and have unstable emotions. That is probably why
treatments that provide this essential element achieve better results than does unstruc-
tured TAU in the community (Linehan et al., 1993).
Empathy and validation are essential elements of any therapy, and are particularly
important for patients with PDs, some of whom are sensitive to the slightest hint of
invalidation (Linehan, 1993). In other words, these are patients who can easily feel
that their emotions are dismissed by others. Feeling invalidated may lead to difficulty
absorbing other aspects of the therapy. When one learns to observe emotions (and not
be derailed by them), one can stand aside from crises and begin to think about
alternative solutions to problems.

Teaching Emotion Regulation Skills

Psychotherapies designed for borderline personality disorder have earned a strong
evidence base (Paris, 2020). However, it is not clear that “any old” psychotherapy will
do. DBT offers an additional component: the teaching of skills that promote emotion
regulation.
Patients usually come to sessions and tell stories about stressful events that have
occurred over the week, and therapists usually validate their feelings. It is easy to see
why this can be helpful, but many patients with borderline personality disorder
misunderstand and distort their interpersonal environment. The danger is that patients
will conclude that we agree with them – that is, that other people are bad, and that they
are victims.
Empathy therefore has to be linked to tactful confrontations to help patients learn
new ways of dealing with their problems, what Bateman and Fonagy (2006) call the
capacity to “mentalize,” and what Linehan (1993) calls a “dialectical” approach (i.e.,
understanding why it is hard to change, but encouraging patients to change anyway).
Therefore, therapy needs to promote change, based on a strong enough alliance that
allows patients to see their problems in a different light.
These principles help us to understand why psychodynamic therapy has often been
ineffective for patients with borderline personality disorder. There are clinical trials
supporting transference-focused therapy (Doering et al., 2010), but that is a major
adaptation of the psychodynamic approach. Most patients who mentalize, or who are
constantly in the throes of emotion dysregulation, cannot make use of procedures such
as free association with a relatively silent therapist who only intervenes to make
“interpretations.”
 Borderline Personality and Other Disorders 271

Box 15.1 Self-Injurious Thoughts and Behaviors in Youth

There has been an increase in the prevalence of suicidal ideation and/or nonsuicidal
self-injury (NSSI) in young people. Although many adolescents who engage in NSSIs are
experimenting, those that continue to do so are more likely to develop borderline
personality disorder (Biskin et al., 2021). In a systematic review, DBT has been
characterized as a well-established treatment (i.e., having strong research support) for
youth with both suicidal ideation and deliberate self-harm (Glenn et al., 2019). Within
the DBT framework, suicidal ideation and NSSIs are viewed as ways to control
emotional dysregulation when distress feels overwhelming. They can also be a way to
communicate distress to others (Nock, 2009).

Present-Oriented Focus
If therapy focuses on the past rather than the present, patients are more likely to be mired
down than to “work through” past events. There may also be problems in focusing
excessively on re-experiencing traumatic events from childhood. Koenigsberg (2010)
has shown that patients with borderline personality disorder do not habituate to stressful
thoughts, but that they become increasingly activated and disturbed as they repeatably
try to process them. This may help to explain the regression and increasing symptom
levels so often seen in therapies that focus on traumatic events.
Therapies that are present-oriented, have a strong cognitive component, balance
acceptance and change, offer a predictable structure, and in which therapists are active
and engaged are more likely to succeed. They place more importance on the present
than the past.

Approaches for Other Personality Disorders

The most researched PD is borderline personality disorder, as this diagnosis describes
patients who often come for treatment and who place great demands on mental health
practitioners. The picture is quite different in community studies that include those who
meet criteria for a PD but do not usually seek therapy (Trull et al., 2010). The picture is
also different in clinical settings where systematic evaluations of PD are routinely
conducted. In a large outpatient clinic (n=859), Zimmerman et al. (2005) examined the
clinical prevalence of the various categories of PD described in the DSM-IV. Of the total
PD cases, somewhat less than half of patients, somewhat less than half of all patients, the
most frequent were avoidant personality disorder, at 14.7%, followed by unspecified
personality disorder at 14.1%. Other more frequent PDs included borderline personality
disorder (9.3%), obsessive-compulsive personality disorder (8.7%), paranoid personality
disorder (4.2%), antisocial personality disorder (3.6%), and narcissistic personality
disorder (2.3%). All other categories were quite rare (less than 2% of the total).
272 Joel Paris

Unspecified Personality Disorder

Unspecified personality disorder is the most common PD that clinicians see, even if
this diagnosis is not always made (Zimmerman et al., 2005). What this means is that
most patients do not fit into any of the DSM categories. Thus, any patient who meets
the overall criteria for a PD but does not meet criteria for any specific category can
qualify for this diagnosis, if one carefully follows the rules in the DSM-5-TR. The
question is whether this is a meaningful entity or a “wastebasket.” There are no data
concerning specific treatments. The fact that so many PDs cannot be specified points
to the many serious weaknesses in the DSM-5-TR system.

Avoidant Personality Disorder

Avoidant personality disorder is one of the most common disorders seen in clinics
(Zimmerman et al., 2005); however, since there are no established methods for
treating these patients, they may not receive psychotherapy. Avoidant personality
disorder has a large overlap with social anxiety disorder, so some of the literature on
treatment describes CBT methods originally developed for social anxiety (Sanislow
et al., 2012). But there is no specific protocol for treating the PD, and there have been
no clinical trials (a Cochrane Report was proposed at one point, but it was withdrawn
for lack of research evidence).

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder (OCPD) is a trait disturbance that fades
imperceptibly into high conscientiousness or to normality, but can affect interpersonal
functioning (Cain et al., 2015). Inspired by DBT, Lynch (2018) has described
a method for treating OCPD called radically open dialectical behavior therapy,
which offers a protocol for treating disorders of over-control (as opposed to under-
control). There is some evidence that this approach is useful for refractory depression
(Lynch, 2018), and the method has gained approval from the Society of Clinical
Psychology as having modest support for depression (SCP, n.d.b.), but further clinical
trials are needed to fully assess its efficacy.

Antisocial Personality Disorder

Antisocial personality disorder (AsPD) has been heavily studied for etiology, course
over time, and implications for criminal law (Black, 2022), but there is little evidence
of effective treatments for AsPD. We do not have any strong empirical evidence that
AsPD can be managed in therapy. And, given the low level of treatment-seeking, it is
not clear that research on treatment would even be practical. Most of these patients are
 Borderline Personality and Other Disorders 273

seen in forensic settings and do not ask for treatment to cope with their inner suffering;
rather, they are more focused on avoiding the consequences of their behavior.
Therapists who are not working in a correctional setting rarely see such patients and
tend to avoid treating them if they do. For those working within a correctional setting,
Chapter 14 on antisocial behavior is a good resource.

Narcissistic Personality Disorder

Although relatively uncommon in practice, a good deal of clinical literature, mostly
from psychoanalysts, has focused on narcissistic personality disorder. A large hand-
book of narcissistic personality disorder and trait narcissism (Campbell & Miller,
2011), as well an edited book on treatment (Ogrodiczuk, 2013), have described many
potential methods of therapy, but no RCTs have been conducted. Moreover, people
with narcissistic traits tend to blame others for their problems, making a therapeutic
alliance more difficult. In the absence of data telling clinicians what works (and what
doesn’t work) for narcissistic personality disorder, we may need a therapy package
that is specific to this disorder, and that targets its most problematic aspect, paralleling
what Linehan did for borderline personality disorder.

Dependent Personality Disorder

Dependent personality disorder is defined in the DSM-5-TR by criteria that
describe the same problem in different contexts, which might lead one to ask
“how many ways can people be overly dependent?” The category was close to
being dropped from the DSM-5, but it was retained when the decision was made
to retain all diagnoses from the previous edition, and to put Alternative Model of
Personality Disorders (AMPD) into Section III of the manual. Bornstein (1992) is
one of the few researchers interested in dependent personality traits which lead to
major difficulties in life. There is no specific protocol for treating patients with
dependent personality disorder, and as yet there has been little active research or
clinical trials on this topic.

Other Personality Disorders

The other PDs listed in DSM-5-TR have attracted even less research interest. Four
PDs (histrionic, schizoid, paranoid, and dependent) were removed from the original
proposals for DSM-5, and although they can still be found in Section II of the manual,
they are absent from the “hybrid” AMPD in Section III (APA, 2022). The retention of
two other categories (avoidant personality disorder and obsessive-compulsive per-
sonality disorder) in Section II may have been based on the fact that they were
examined for long-term outcome in the Collaborative Longitudinal Study of
274 Joel Paris

Personality Disorders (CLPS; Gunderson et al., 2011). However, research on these

diagnoses remains thin.
Schizotypal, schizoid, and paranoid PDs are generally seen as falling within
a schizophrenic spectrum, since they are associated with a family history of psychosis,
with which they share some biomarkers (Esterberg et al., 2010). The hybrid proposal
in Section III of DSM-5-TR folds all of these disorders into a single category of
schizotypal personality disorder.
Histrionic personality disorder belongs to the history of psychiatry and is rarely
diagnosed today (Novais et al., 2015). Decades ago, “hysteria” was used to describe
a wide range of patients, some of whom had personality traits associated with

Box 15.2 Therapy for Personality Disorders Based on Trait Dimensions

The ten categories of PD retained in Section II of DSM-5-TR do a poor job (with the
important exception of borderline personality disorder) of describing the range of
psychopathology described by the PD construct as a whole. They are derived from
traditional labels that do not correspond to the factors identified by trait psychology. In
contrast, dimensional systems tend to track the Five Factor Model of Personality
(Widiger & Costa, 2013).
One of the innovations in the AMPD model in Section III of DSM-5 was the use of
trait dimensional profiles to build PD diagnoses of categories (Hopwood et al., 2019).
The five overall dimensions are negative affectivity, detachment, antagonism,
disinhibition, and psychoticism. In principle, one might treat traits such as emotion
dysregulation, impulsivity, or social avoidance with methods specific to these
characteristics. At this point, no one has proposed such a protocol. Research up to now
has focused on the validity and reliability of the AMPD. That could change if the model in
Section III of the manual were allowed to replace the categories in Section II. However,
to date, no clinical trials of psychotherapy have been based on the AMPD. Moreover, the
system is fairly complex, and clinicians may be reluctant to use it unless it can be shown
to aid the treatment of patients with PDs.
The International Classification of Diseases, 11th edition (ICD-11; World Health
Organization, 2018) has introduced dimensional diagnoses for most cases of PD. It only
retained one category of borderline personality disorder, which can now be rated as
a “borderline pattern,” to be scored on top of the general features of all PDs. The five
dimensions to be scored are Negative Affectivity, Detachment, Disinhibition,
Dissociality, and Anankastia (compulsivity), and clinicians can also code severity. No
protocols have been developed to apply these traits to psychotherapy, and there have
been no clinical trials using this system.
In the end, the DSM system remains predominant in clinical practice. One reason is
that it is familiar to most clinicians; another reason is that each of the alternatives have
problems of their own.
 Borderline Personality and Other Disorders 275

stimulus-seeking, high extraversion, and a dramatic style of communication. The

disorder was renamed “histrionic” to emphasize the dramatic flair believed to charac-
terize these patients, most of whom are female. But it is fair to say that with almost no
research support, this category can easily be dropped from the DSM.

Other Variables Influencing Treatment

Assessment and Diagnosis
The most important thing to know about PDs is that they are often missed in clinical
evaluations. Diagnosis is strongly influenced by what mental health professionals
have in their treatment armamentarium. A failure to acknowledge PDs has been well
documented (Paris, 2020). The main reason is the focus of both pharmacologically
oriented physicians and cognitively oriented psychologists on targeting symptoms.
Another is that many patients with PDs need therapies that are expensive and often
poorly insured.

Comorbidity
Comorbidity is a misleading term because it seems to imply that patients have more
than one disorder. In fact, the diagnostic system tends to favor multiple diagnoses that
overlap with each other. By and large, successful treatment of PDs can be effective in
managing a wide range of symptoms.

Demographics
In clinical settings the vast majority of patients with PDs are female (Zimmerman
et al., 2008). However, research in community samples shows that there is a large
number of males who have the same disorders but do not seek help (Trull et al.,
2010). There is very little research on ethnicity or race in PDs, though a report
based on a large sample in the UK suggested that Black people have a lower
prevalence than do White people (McGilloway et al., 2010). It may be relevant
that Black people also have a much lower rate of suicide than do White people
(Ramchand et al., 2021).

Medication
Even as specific therapies for borderline personality disorder have been developed
and researched, patients may still receive mainly pharmacological treatment. Since
the symptoms of borderline personality disorder overlap with mood or anxiety
disorders, a PD diagnosis may not even be made. Yet research shows that patients
with PD diagnoses, even when depressed or anxious, do not consistently benefit from
pharmacotherapy (Newton-Jones et al., 2006). Ironically, when patients fail to
276 Joel Paris

respond to these agents, they can receive more aggressive pharmacotherapy leading to
polypharmacy. When a nonpsychotic patient is taking five or more medications, it is
worth considering whether they may have a PD that does not respond to any of these
agents.

Conclusion
Research on PDs, especially borderline personality disorder, has made great progress
in the last few decades. We now know that many (if not most) patients with borderline
personality disorder do well in the long run. Psychotherapy specifically designed for
this population can speed up this recovery process. However, we do not yet know
whether these findings can be applied to other categories.
These findings support a more optimistic view of treatment for borderline person-
ality disorder. For many years, this condition has been underdiagnosed or misdiag-
nosed. This is much less true now, as clinicians have become aware that therapy tends
to be effective. But borderline personality disorder is a diagnosis that affects at least
1% of the general population (Trull et al., 2010) and is much more common in clinical
populations (Zimmerman et al., 2005).
Other PDs need more research, and we lack well-validated methods of treating
them. We will lack the resources needed to manage any of these patients unless we can
find a way to shorten therapy and apply the principles of stepped care (Paris, 2015,
2017). One of the unfortunate aspects of the domain of psychotherapy is the existence
of several competing methods, most with a three-letter acronym, with results over-
interpreted by therapists with allegiance to one or another approach. The most
parsimonious conclusion could be that all well-structured methods are superior to
TAU, but that none is clearly superior (Choi-Kain, 2020). There should be only one
kind of psychotherapy for PD – the one that works best. An integrated approach
should use the best ideas from all sources, and put them together into one package
(Paris, 2020). But, given the strong evidence for DBT, its ideas are likely to be
a crucial element in any plan for psychotherapy integration. We now have a good
beginning for identifying effective approaches, but we have a long way to go to make
them accessible.

Useful Resources

• Choi-Kain, L., Sharp, C. (2021). Handbook of good psychiatric management for adolescents
with borderline personality disorder. American Psychiatric Publishing. (up-to-date book on
adolescent PD)
• Linehan, M. M. (2014). DBT skills training manual (2nd ed.). Guilford. (an essential guide
to DBT)
 Borderline Personality and Other Disorders 277

• Paris, J. (2020). Treatment of borderline personality disorder (2nd ed.). Guilford. (up to date
summary of the research literature)
• Porr, V. (2010). Overcoming borderline personality disorder: A family guide for healing
and change. Oxford University Press. (best book for families and patients)

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 16
Psychosis and Schizophrenia
Elizabeth Thompson, Katherine Visser, Madeline Ward,
and Brandon A. Gaudiano

Psychosis is a broad category of mental health symptoms defined by distorted

thoughts and experiences that cause some level of disconnection from reality.
Recent estimates indicate that approximately 1 in 150 individuals worldwide will
develop a psychotic disorder during their lifetime (Moreno-Küstner et al., 2018). On
an individual level, psychosis impairs functional capacity, social engagement, and
quality of life. On a global level, meta-analytic data from 24 countries demonstrate
yearly healthcare costs ranging between $94 million and $102 billion US dollars for
individuals with schizophrenia, one specific and severe form of psychotic disorder
(Chong et al., 2016). In recent years these costs have increased substantially, as 2019
estimates indicate that the economic burden of schizophrenia in the US has reached
$343.2 billion, with the majority of costs attributed to caregiving (33%), premature
mortality (23%), direct health care (18%), and unemployment (16%; Kadakia et al.,
2022).
“Positive” symptoms of psychosis, named as such because they are additional
experiences that are not typically present for most individuals, include hallucinations
(i.e., perceptual experiences in the absence of stimuli), delusions (i.e., belief in ideas
that are extreme or not grounded in reality), and disorganized thoughts or behavior
(i.e., confused or bizarre thoughts, speech, or behavior). In contrast, “negative”
symptoms of psychosis indicate a deficit in typical experiences, such as low levels
of motivation, emotional expression, and social engagement. The presence of positive
and negative symptoms, accompanied by distress and functional interference, are
among the criteria for diagnosing a psychotic disorder (American Psychiatric
Association [APA], 2022). Schizophrenia is one severe form of psychotic disorder
that is often chronic in nature (at least six months) and accompanied by emotional
distress and significant interference in cognitive, social, and role-related functioning
(e.g., school or work). Another persistent form of psychosis is schizoaffective dis-
order, a chronic condition accompanied by major mood episodes (e.g., depression or
mania) for the majority of the illness duration. Other psychosis spectrum disorders
differ in the duration and scope of illness, such as major depression with psychotic
282
 Psychosis and Schizophrenia 283

features or bipolar disorders with psychotic features (psychosis occurring only in the
context of the mood episode), brief psychotic disorder (marked by short duration
symptoms), delusional disorder (defined by delusions only), temporary psychosis
caused by a substance (e.g., recreational drugs or medications) or medical condition,
catatonia (marked by immobility and abnormal or slowed movements), or other
psychotic symptoms that cause some level of distress and interference (e.g., attenu-
ated psychosis, or hallucinations without other psychotic features).

Etiology and Theoretical Underpinnings of Treatment

The diathesis-stress model provides an etiological explanation for the emergence of
psychosis and presents a theoretical framework for multiple empirically supported
treatments. This model suggests that an underlying biological vulnerability, often-
times genetic predisposition (e.g., having a close biological relative with a psychotic
disorder), may interact with an individual’s capacity to manage daily stressors and/or
exposure to traumatic life events, which subsequently contributes to either the onset or
exacerbation of psychotic symptoms (DeVylder et al., 2013; Walker & Diforio,
1997). Stress reactivity is also known to increase following the onset of a psychotic
disorder (Malla et al., 1990), suggesting a decreased capacity to cope with stress
overall. This can lead to increased distress and poorer functioning (Corcoran et al.,
2003). Accordingly, many treatments for psychosis include elements of stress reduc-
tion and emotion regulation skills, to help individuals manage their stress response
(and, thus, help reduce the total symptom burden).
Throughout much of the history of mental health care, the medical model has
focused squarely on a goal of symptom elimination (Resnick et al., 2005). This cure-
focused approach is problematic for many individuals who, despite treatment, con-
tinue to experience symptoms, which can lead to demoralization and overemphasis on
disability and impairment. In contrast, the recovery model takes a person-centered and
strengths-based approach that emphasizes knowledge, empowerment, hope, and
satisfaction with life (Resnick et al., 2004). This model focuses on incorporating
multifaceted, research-backed interventions designed to foster optimism, enhance
collaboration across treatment providers, and incorporate peer support and stigma
reduction while promoting re-engagement with work and valued activities (Warner,
2009). Many of the psychosocial interventions that will be detailed herein rely upon
these tenets.

Brief Overview of Treatments

For decades, randomized controlled trials (RCTs) have demonstrated that certain
psychosocial interventions significantly improve outcomes compared to medication
treatment alone for patients with schizophrenia and related psychotic disorders
284 Thompson, Visser, Ward, and Gaudiano

(Mueser et al., 2013), and, therefore, clinical practice guidelines have recommended
their use (Dixon et al., 2010). However, only a minority of patients are being offered
such interventions to this day (Drake et al., 2009; Kopelovich et al., 2022). Factors
related to the poor uptake of psychosocial interventions for psychosis include the
historically low rates of reimbursement and funding to deliver these types of inter-
ventions relative to medications, the dearth of clinicians who specialize in treating
psychosis, and the lack of systematic training and support for implementing these
empirically supported psychosocial interventions in the community (Kopelovich
et al., 2019).
Antipsychotic medication is considered the front-line treatment for psychosis, at
least during acute episodes (Keepers et al., 2020). Although medications are effect-
ive in targeting positive symptoms of psychosis (i.e., hallucinations and delusions)
for many individuals, they often fail to adequately address negative symptoms,
functioning, and quality of life (Leucht et al., 2017). Therefore, it is critical that the
public and professionals become more educated about the various empirically
supported psychosocial treatments (Solmi et al., 2023) currently available for
patients suffering from psychosis so that they can help to expand the use of these
interventions and ultimately increase their reach and uptake. The psychosocial
interventions for psychosis with the most consistent empirical support to date are
briefly summarized next.

Cognitive-Behavioral Therapies
Cognitive-behavioral therapy for psychosis (CBTp) is an adaptation of traditional
CBT, which is one of the best-validated therapies for treating common psychiatric
conditions, including depressive and anxiety disorders (Hofmann et al., 2012). CBTp
posits that psychotic symptoms are, at least in part, due to and maintained by common
cognitive information processing biases, such as “jumping to conclusions” and other
attributional biases that cause distorted perceptions and reasoning (Garety et al.,
2005). CBTp aims to address these underlying cognitive biases and related behavioral
manifestations to decrease distress, improve functioning, and help patients better cope
with their psychotic experiences. There is no one specific CBTp treatment program,
but rather many variations around this theme (Morrison & Barratt, 2010); all such
approaches are structured, emphasize a collaboration between patient and therapist to
work on present-focused goals, include in-session skills training, and involve
between-session practice (i.e., homework; Morrison et al., 2004). Common cognitive
and behavioral techniques are first applied to nonpsychotic symptoms, such as
depression and anxiety (Kingdon & Turkington, 2005). Such strategies include
Socratic questioning aimed at identifying and correcting distorted thinking patterns,
with the use of corresponding behavioral experiments to test out faulty assumptions.
As therapy continues and trust is established, the therapist slowly applies Socratic
 Psychosis and Schizophrenia 285

questioning and behavioral experiments to hallucinations and delusions in

a nonargumentative and collaborative fashion based on the patient’s comfort and
motivation levels. Additional strategies are employed for negative symptoms, such as
behavioral activation and social skills training, as appropriate.
The current National Institute for Health and Care Excellence (NICE, 2014)
guidelines for psychosis and schizophrenia recommend that individual therapy with
CBTp be provided to patients in all phases of illness (early, acute, and chronic) and
that it be delivered in hospital and outpatient settings. These recommendations are
based on evidence from multiple RCTs and more than 20 meta-analyses that have
found CBTp to be helpful for improving symptoms and functioning in schizophrenia
(Kingdon & Turkington, 2019). For example, one meta-analysis of RCTs demon-
strated that CBTp produces significant improvements compared to supportive therapy
on overall symptoms (g = 0.42) and positive symptoms (g = 0.23) (Turner et al.,
2014).

Assertive Community Treatment

Assertive community treatment (Stein & Test, 1980) was developed in the 1970s in
the United States to address the problem of frequent rehospitalizations for patients
with severe mental illness (SMI), including schizophrenia, which resulted from the
deinstitutionalization movement of the 1950s (Dixon, 2000). Assertive community
treatment is a model of care rather than a specific treatment, and over the years it has
been adapted and implemented successfully in many countries around the world
(Rochefort, 2019). The program is multidisciplinary, multicomponent, and holistic
in that it includes a range of services such as psychotherapy, family support, and
medication, as well as housing, finance, and education/work support (Bond & Drake,
2015). Furthermore, the team provides services directly to patients and there is
a low client-to-staff ratio given the intensity of treatment. Because patients leaving
the hospital often have poor rates of engagement with community treatments
(Kreyenbuhl et al., 2009), an assertive outreach approach is used to support patients
remaining in treatment on a long-term basis.
Based on more than 45 years of efficacy and effectiveness research, assertive
community treatment is recommended as a gold-standard intervention in treatment
guidelines for schizophrenia (Thorning & Dixon et al., 2017), and meta-analyses have
shown that the program reduces days hospitalized (mean reduction = –0.86 days) and
improves treatment retention (relative risk = 0.70) (Dieterich et al., 2017). Evidence
has been less consistently found for its ability to improve housing, symptom manage-
ment, and quality of life, as these outcomes have varied based on the particular study.
Recent work has focused more on addressing implementation challenges and deter-
mining how best to integrate assertive community treatment into modern and ever-
changing healthcare systems (Thorning & Dixon, 2020).
286 Thompson, Visser, Ward, and Gaudiano

Family Therapy
Family therapy is based on the premise that it is not just the affected individual who
needs to understand their symptoms and diagnoses; family members should also be
included as collaborators, provided with psychoeducation, and taught skills to support
their loved one in treatment and at home (Mueser et al., 2015). Family programs are
designed to educate families on the signs and symptoms of psychosis and biomedical
aspects of psychopathology, while also helping family members to build skills in
communication, problem solving, and assisting the client in setting and working
toward treatment goals (Mueser et al., 2015). A primary goal of this family work is
to reduce family conflict and stress while bolstering empathy and familial support,
thereby minimizing vulnerability for relapse and comorbid mental health concerns
(e.g., mood and anxiety symptoms, substance use, trauma).
Family therapy has been indicated as one of the first-line treatments for psychotic
disorders, along with antipsychotic medication, with a specific emphasis on psycho-
education early on in treatment (NICE, 2014). There is a strong evidence base for
family therapy and psychoeducation (Rodolico et al., 2022; Solmi et al., 2023), and
family therapy is central to several empirically supported interventions, including
family-aided assertive community treatment (FACT; McFarlane at al., 1992), family-
focused therapy (FFT; Miklowitz et al., 2014), and the Navigate Family Education
Program (Glynn & Gingerich, 2020; Mueser et al., 2015). Additionally, family
therapy is routinely included at the start of other individual therapies, including
CBTp (Steel & Smith, 2013).

Social Learning/Token Economy Programs

Social cognition deficits are considered a significant problem in schizophrenia
(Green et al., 2015). Social skills training (SST) refers to several similar interventions
developed to ameliorate social cognition deficits in schizophrenia by providing
structured instruction on core social skills (e.g., how to begin or leave
a conversation, how to say “no”). Skills are taught in a stepwise, scaffolded fashion
that incorporates role-play, feedback, and coaching, frequently in a group format
(Wallace et al., 1980). SST is recommended by the American Psychiatric Association
as part of their guidelines for the treatment of schizophrenia (Lehman et al., 2004).
Research indicates that SST is helpful in learning social skills, decreasing negative
symptoms of schizophrenia above and beyond the impact of medication, and improv-
ing functioning in the community (Kurtz & Mueser, 2008; Turner et al., 2018). Meta-
analytic research indicates significant improvements in negative symptoms (e.g.,
blunted affect, social withdrawal, rapport) in particular, as well as general symptoms
(e.g., anxiety, depression, attention) in comparison to control samples (e.g., treatment-
as-usual, waitlist controls), but effects were not found for positive symptoms (Turner
et al., 2018). Importantly, there are some concerns as to the generalizability of skills
 Psychosis and Schizophrenia 287

into daily life (NICE, 2014), and more research is needed to assess sustained effects
across time (Turner et al., 2018).
SST began to be implemented around the same time as another intervention
purported to assist with reinforcing appropriate social engagement: token economies
(Dickerson et al., 2008; Hersen, 1976; Kazdin, 1977). Based on the principles of
operant conditioning (Skinner, 1953) and initially implemented in psychiatric hos-
pitals, token economies involve providing patients with “tokens” to attempt to
reinforce desired behavior. The type and purpose of the token varies and is unique
to each setting implementing such a program. Research indicates that providing
behavioral reinforcement in this manner is effective in institutional settings, primarily
for addressing problematic behaviors (Dickerson et al., 2008; Lecomte et al., 2014).

Supported Employment
Individuals with psychotic disorders often have ongoing difficulties in “role func-
tioning” (i.e., engaging in and fulfilling school and/or work responsibilities), and
role functioning has been linked to positive, negative, disorganized, and cognitive
symptoms, as well as social dysfunction (Dickinson et al., 2007; Fulford et al., 2013;
McGurk & Mueser, 2004). Given marked difficulties in vocational functioning
among adults with psychosis, supported employment interventions were designed
to provide vocational placement and skills development, aiming to improve employ-
ment outcomes for participants (Mellen & Danley, 1987). Specifically, supported
employment interventions assess the strengths and abilities of clients, help them to
obtain competitive work that aligns with their preferences in community settings,
navigate disclosure of mental health difficulties to employers, plan for job supports,
and offer training in skills necessary for gaining and maintaining employment
(McGurk & Mueser, 2004).
Meta-analytic studies (Modini et al., 2016) and nontrial routine programs (Richter
& Hoffmann, 2019) indicate that individuals who engage in supported employment
interventions such as individual placement and support (IPS) have been shown to be
more than twice as likely to gain competitive employment when compared to trad-
itional vocational rehabilitation programs (i.e. a tiered training approach that begins
with sheltered job placement in low-paying, segregated settings for individuals with
mental illness; Lutfiyya et al., 1988). Supported employment outcomes are sustained
over the course of multiyear follow-ups, and international evidence indicates that
outcomes associated with IPS were not impacted by geographic location or
unemployment rates, suggesting the effectiveness of these interventions across dif-
ferent settings and economic circumstances (Modini et al., 2016). Furthermore,
participation in supported employment programs may weaken the negative influence
of symptoms (e.g., cognitive, negative, and positive symptoms) on work functioning
by bolstering compensatory skills (McGurk & Mueser, 2004), and participation in
288 Thompson, Visser, Ward, and Gaudiano

work has been linked to greater social functioning, fewer symptoms, and sustained
periods of remission (Burns et al., 2009).

Cognitive Remediation
Cognitive impairments are a well-studied symptom of schizophrenia (Schaefer et al.,
2013). Cognitive remediation is an umbrella term referring to skills-building inter-
ventions created to improve cognitive functioning across multiple domains (including
processing speed, attention, working memory, visual learning, verbal learning, prob-
lem solving, and social cognition; Wykes et al., 2011). These interventions, which are
also often used to assist individuals who have developed a traumatic brain injury, may
include use of a specialized computer program (Fisher et al., 2009) or involve
a trained therapist providing instruction in compensatory skills.
Cognitive remediation is well studied in schizophrenia and consistently shows
improvements across phases of the disorder (Revell et al., 2015) and multiple domains
of cognitive functioning (McGurk et al., 2007). Meta-analytic research also indicates
that cognitive remediation not only improves cognitive function but is also linked
to improvements in psychosocial functioning as well as symptom improvement
(McGurk et al., 2007), particularly when combined with psychiatric rehabilitation
(Fitapelli & Lindenmayer, 2022). While, similarly to SST, there have been questions
about the generalizability of cognitive remediation interventions, research does indi-
cate that there are small generalized effects on cognitive functioning dimensions
excluded from instruction (e.g., social cognition and global function), particularly
when provided in psychiatric rehabilitation settings (Vita et al., 2021).

Peer Support
Peer support for psychosis consists of services and support from individuals who
have lived experience (i.e. experienced psychosis themselves; Davidson et al., 2006).
Peer-support programs are not based on psychiatric models and may not be theory
driven; however, service users, researchers, and professionals have advocated for
these programs as they align with the recovery model. Specifically, peer-support
services include information about psychosis, effective use of medication, identifica-
tion and management of symptoms, access to services, coping with stress, crisis
planning, building social support, preventing relapse, and setting personal recovery
goals (Lloyd-Evans et al., 2014).
A systematic review and meta-analysis of 18 trials consisting of mutual support,
peer support, and peer-delivered service programs found considerable variation
across program content (Lloyd-Evans et al., 2014). While there was evidence for
gains in measures of hope, recovery, and empowerment that were maintained beyond
the end of peer-support programs, heavy risk of bias was noted in these studies, and
 Psychosis and Schizophrenia 289

lack of consistency between programs led to inconsistent findings. Current guidelines

(Dixon et al., 2010; NICE, 2014) suggest peer support should be delivered by a trained
individual who has recovered or is stable in their illness. Further, peer-support
specialists should be embedded within a care team and receive support and mentor-
ship from other experienced peer workers (DuBrul et al., 2017).

Credible Components of Treatments

Although the previous section illustrates the various specific empirically supported
treatments that have been found to be effective for treating psychosis, each of these
treatment packages contains a number of different elements and components, many of
which are shared across interventions. Rosen and Davison (2003) argued that it is
crucial to understand and promote empirically supported principles of change that
may underlie effective therapies, rather than just the specific treatment packages
themselves. In the remainder of the chapter, we describe the most credible treatment
components that can be distilled from what we currently know about effective
approaches to treating psychosis.

Psychoeducation
Because psychosis can be characterized by a lack of insight (McCormack et al., 2014),
psychoeducational approaches are important to increase both knowledge and insight
about one’s illness and treatment options in order to improve coping skills.
Psychoeducation is also a useful tool to normalize experiences and reduce stigma,

Box 16.1 Support and Empathy

Chapter 21 highlights the importance of therapy relationship variables, but they warrant
a brief mention in this chapter as well. The so-called “nonspecific” or “common” factors
of psychotherapy (e.g., alliance, empathy, genuineness, etc.) play a significant role in
treatment outcomes regardless of therapy modality (Wampold, 2015). Empathy – the
process by which therapists communicate compassionate understanding of a client’s
experience – is considered a primary common factor (Wampold, 2015) and significantly
influences therapy outcomes (Elliott et al., 2011). Furthermore, research indicates that
when therapists are perceived as genuine and empathic by their clients with
schizophrenia, alliance is likely to improve (Shattock et al., 2018). As individuals with
schizophrenia are known to experience social cognition difficulties (Green et al., 2015)
that may impact the extent to which they can develop supportive relationships (Hooley,
2010), and individuals with paranoid delusions in particular may have difficulty
establishing trust, a warm, empathic, supportive relationship with a therapist may be an
important and primary source of connection and recovery.
290 Thompson, Visser, Ward, and Gaudiano

particularly internalized stigma, which can improve treatment adherence and bolster
hope (Xia et al., 2011). Incorporating psychoeducation into psychosocial treatment
for psychosis has been shown to reduce relapse and readmission and to encourage
medication adherence, thus demonstrating both clinical and economic benefits, and its
benefits extend to both the patient and their caregivers (Xia et al., 2011; Maheshwari
et al., 2020). Psychoeducation is best provided within the framework of the recovery
model and in the context of a broader intervention such as CBTp or family therapy,
rather than in isolation.

Skill Acquisition
CBTp, family psychoeducation, SST, and other therapies for psychosis all teach
patients effective coping skills and strategies for managing illness and promoting
recovery. Such strategies include goal setting, symptom identification and monitor-
ing, functional analysis to understand the antecedents and consequences of behaviors,
examination of interfering/avoidance behaviors, problem solving, treatment adher-
ence promotion, social and communication skills, stress management, behavioral
activation, exposure exercises, cognitive change techniques (e.g., Socratic question-
ing), use of worksheets and between-session homework assignments, safety planning,
and relapse prevention work (Morrison & Barratt, 2010; Mueser et al., 2013). Thus,
empirically supported psychotherapies for psychosis tend to incorporate a wide range
of techniques and strategies based on their particular theoretical frameworks to help
patients actively cope with their symptoms and improve their ability to function
(Dickerson & Lehman, 2011).

Emotion Regulation
Emotion regulation is defined as the use of strategies to decrease the frequency,
intensity, and/or duration of emotional responses (Gross, 1998). Such strategies are
frequently taught in cognitive-behavioral interventions such as CBTp. For example,
identifying and shifting thought distortions can be thought of as a form of the
cognitive reappraisal emotion regulation strategy; cognitive reappraisal is considered
an important mechanism of change for CBTp patients (Morrison et al., 2017).
Research has indicated that individuals with schizophrenia try to regulate their
emotions but may utilize less contextually appropriate strategies and implement
them less effectively than healthy individuals (Visser et al., 2018). This has important
treatment implications, as individuals with psychotic symptoms are shown to be
increasingly sensitized to stress, which is linked to worsening symptoms (Myin-
Germeys et al., 2005). Furthermore, meta-analytic findings indicate that individuals
with psychotic disorders may use more maladaptive emotion regulation strategies,
which are associated with positive symptoms (Ludwig et al., 2019). Accordingly,
 Psychosis and Schizophrenia 291

including supportive instruction in coping skills that are designed to effectively

regulate emotion (e.g., cognitive reappraisal, emotion regulation-focused components
of dialectical behavior therapy [Linehan, 1987]) can be a powerful component of
interventions delivered to individuals with psychosis and aid with the management of
negative emotions in particular (Ludwig et al., 2020; Opoka et al., 2021). Such
interventions may aid in increasing belief in the ability to manage negative emotions
(Khoury et al., 2015, Ryan et al., 2021; Lawlor et al., 2022), improve symptoms of
anxiety and depression (Khoury et al., 2015), foster confidence and hope, increase
motivation toward goals (Ryan et al., 2021), and improve self care (Khoury et al.,
2015). However, generalization of research-taught skills into daily life is unclear
(Lawlor et al., 2022). Research in this area is ongoing.

Interpersonal Support
Family-focused intervention strategies aim to reduce family stress, as research sug-
gests that family conflict may influence the course of psychotic illness over time
(O’Driscoll et al., 2019). High levels of “expressed emotion,” characterized by family
members’ emotional overinvolvement and critical or hostile attitudes toward the
individual with schizophrenia, are consistently associated with negative outcomes
(e.g., relapse, rehospitalization; Amaresha & Venkatasubramanian, 2012; Butzlaff &
Hooley, 1998). The negative impact of expressed emotion may be particularly
harmful for those in the early phases of illness who are more likely to reside with
parents and family caregivers (Miklowitz et al., 2014). Family therapy focused on
psychoeducation, problem solving, and healthy communication skills may bolster
perceived caregiver support, as well as decrease stress and increase family function-
ing (Glynn & Gingerich, 2020; McFarlane, 2016; Miklowitz et al., 2014).
Interpersonal relationships outside of the family are also important to consider in
the context of treatment. Given that diminished social functioning and skills deficits
are common among individuals with psychotic disorders, interventions targeting
social skills and building social connectedness are an integral part of the recovery
process. Social impairments seem to emerge prior to illness onset, are linked to
increased risk for future psychosis among individuals at clinical high risk
(Addington et al., 2019), and are often persistent, impacting long-term quality of
life. Smaller networks of social support among people with psychosis have been
linked to negative outcomes including hospitalization, poorer functioning, and worse
symptoms (Mazzi et al., 2018). In addition to previously reviewed SST and peer-
support interventions, enhancing social integration through involvement in social
activities and building meaningful interpersonal relationships (with peers and roman-
tic partners) may be important to expand an individual’s support network beyond
family, enhance feelings of belongingness and self-confidence, and reduce internal-
ized stigma, loneliness, and isolation (Mazzi et al., 2018).
292 Thompson, Visser, Ward, and Gaudiano

Care Coordination
A core feature of empirically supported treatment for schizophrenia and psychosis is
care coordination, which can include case management and involves the organization
and integration of client-care activities in the community (Edwards et al., 1999).
Information-sharing, service linkage, and treatment planning across a team of multi-
disciplinary providers promotes more consistent, safer, and effective care for each
client. Case coordination within mental health services (e.g., psychiatry, psychosocial
therapy, and other skills-based interventions such as vocational, cognitive, and social
skills supports) and across physical health services is emphasized within the NICE
guidelines (2014) and is integral to the assertive community treatment model
described earlier. Given the complex needs of many individuals with psychosis,
including the high rates of comorbid mental (e.g. depression, suicidality, trauma,
substance use) and physical (e.g., metabolic, cardiovascular, sleep, and nutrition)
concerns, coordination of services is particularly important to ensure that clients are
receiving the wraparound care they need in a timely and effective manner.

Approaches for Youth

Early-onset schizophrenia, defined as onset prior to the age of 18, is rare, with
incidence estimated to be less than 0.04% of the population, and childhood-onset
schizophrenia (prior to age 13) affects less than 1 in 10,000 children (Stevens et al.,
2014). Despite the rarity of full-threshold schizophrenia among children, research
indicates that early signs of psychosis often develop during later adolescence, as up to
20% of adults report onset of symptoms prior to the age of 18 (Maloney et al., 2012;
Stevens et al., 2014). Thus, recent research has highlighted that schizophrenia and
other psychotic disorders can be considered from a developmental framework, as
subthreshold symptoms often appear in advance of a diagnosable disorder and may
appear early in childhood. Given the young age and ongoing neural development of
young individuals, certain special considerations need to be highlighted when treating
children and adolescents, and treatments should be tailored to individual presentations
and needs. If a young person is showing signs and symptoms of psychosis but has not
yet developed a fully diagnosable disorder as indicated by thorough assessment,
psychosocial treatments should be considered the first-line approach, as opposed to
antipsychotic medications that may impact the developing brain and are known to
have increased metabolic impacts on pediatric populations (Conroy et al., 2018). On
the other hand, antipsychotics have demonstrated efficacy for younger individuals
who have a full-threshold disorder, and as younger age does often equate to increased
severity and poorer prognosis (Eggers & Bunk, 1997), antipsychotics are typically
recommended despite the concerns related to high-potency antipsychotic medications
(McClellan & Stock, 2013).
 Psychosis and Schizophrenia 293

Similar to adult intervention, the NICE guidelines for treatment of child and
adolescent psychosis include FFT, with an emphasis on psychoeducation and adap-
tive skills to enhance problem solving and crisis management while incorporating the
family’s preferences (NICE, 2013). Family-focused intervention is particularly
important for children given their reliance on and cohabitation with caregivers.
In addition, the team-based coordinated specialty care (CSC) service model is
a recovery-oriented treatment program for people with first-episode psychosis,
including adolescents (Dixon et al., 2018). CSC teams take a multidisciplinary team
approach to care in order to enhance supports through wraparound care. Services for
these youth emphasize coordinated support services for the school setting, age-
appropriate peer groups focused on normalization, social skills acquisition, emotion
regulation, and interventions targeting identity-related and transition-age issues.
Evidence-based individual therapy for this age group includes CBT, with a focus on
psychosis and/or comorbid difficulties (e.g., depression, anxiety, trauma) as indicated.

Other Variables Influencing Treatment

Assessment and Diagnosis
Prior to the initiation of treatment, thorough assessment is necessary to determine an
individual’s specific diagnosis, as the presentation and type of psychotic disorder will
drive treatment planning. There are several well-validated clinician-administered
interviews that systematically assess diagnostic criteria for various mental health
disorders and include specific modules for psychosis spectrum disorders. Examples
of comprehensive gold-standard interviews include the Structured Clinical Interview
for DSM-5, Clinician Version (SCID-5-CV; First et al., 2016) which is specific to
adults. There are also several psychosis-specific interviews that assess the full spec-
trum of experiences (e.g., attenuated and psychotic intensity symptoms) and are
specifically designed to probe subtle characteristics that distinguish psychosis-risk
syndromes from various presentations of full-threshold psychosis (e.g., the Structured
Interview for Psychosis-risk Syndromes or SIPS; McGlashan et al., 2001). These
structured interviews and other clinician-rated symptom checklists (e.g., Positive and
Negative Syndrome Scale or PANSS; Kay et al., 1987) can also be used to track
symptom changes (e.g., persistence, progression, or remission of symptoms) over
time and with treatment. In addition to thorough diagnostic evaluation, neuropsycho-
logical and cognitive assessment, measurement of social and role functioning, and
medical workups are recommended to inform conceptualization, rule out nonpsychia-
tric factors that may better explain or contribute to symptoms, and guide treatment
goals.
The particular type of psychotic disorder for which the patient meets diagnostic
criteria can impact prognosis and treatment response. For example, patients with
294 Thompson, Visser, Ward, and Gaudiano

mood disorders (depressive or bipolar) with psychotic features will no longer exhibit
psychotic symptoms when their mood episode remits (Rothschild, 2013).
Furthermore, patients with schizoaffective disorder (i.e., who meet full criteria for
schizophrenia along with having repeated mood episodes) tend to have better out-
comes compared with those with schizophrenia, and patients with psychotic mood
disorders have better outcomes than do patients with either schizophrenia or schi-
zoaffective disorder (Harrow et al., 2000). Additionally, some patients with schizo-
phrenia develop chronic symptoms and treatment resistance, whereas others
demonstrate symptom remission with treatment, although full functional recovery
(i.e., return to pre-illness functioning) is difficult to attain and maintain for the
majority of patients with schizophrenia (Haro et al., 2018).

Comorbidity
Comorbid medical or psychiatric conditions are common in individuals with schizo-
phrenia, impacting at least half of those diagnosed (Carney et al., 2006; Green et al.,
2003). Accordingly, assessing and treating comorbid conditions (e.g., depression,
anxiety, substance use, PTSD) along with the primary psychotic disorder may be
essential in providing the most impactful and effective care. Of particular note,
individuals with schizophrenia are at high risk for suicide, particularly in the year
following a first episode (Carlborg et al., 2010). Medical comorbidities are also
a concern as they can impact quality of life and increase the likelihood of comorbid
depression (Carney et al., 2006). Unfortunately, individuals with schizophrenia are
more likely to experience more disease across a variety of domains (including
cardiovascular, pulmonary, neurological, and endocrine conditions) as compared to
the general population, and they are more likely to die prematurely (Olfson et al.,
2015).

Demographics
Psychotic disorders most frequently onset between late teens and early 30s, with men
typically being diagnosed from late teens to early 20s, and women from early 20s to
early 30s, with an additional peak in postmenopausal women, possibly due to the
protective effects of estrogen diminishing with age (Falkenburg & Tracy, 2014;
McGrath et al., 2008). The five years following onset are often considered a critical
period in treatment in terms of psychoeducation and future treatment engagement, as
well as reducing risk of relapse. Men and women also tend to show differences in
symptom presentation, with men showing more negative symptoms and the content of
positive symptoms differing across genders (Falkenburg & Tracy, 2014). Psychosis
diagnoses may also be more common in transgender individuals compared to cisgen-
der peers, although more research is needed in this area (Barr et al., 2021). These
 Psychosis and Schizophrenia 295

demographic differences among patients with psychosis have implications for both
psychopharmaceutical and psychosocial treatments. There may be risk for overdiag-
nosis/misdiagnosis due to bias, and gender affirmation and tailored care may be more
important in treatment for these individuals. Finally, an array of health disparities
exist in racial/ethnic minority patients with serious mental illness, including diagnos-
tic biases, reduced quality of services, poorer outcomes, increased stigma, and lower
levels of treatment engagement (Maura & Weisman de Mamani, 2017). Thus, clin-
icians may need to place greater emphasis on facilitating trust in the healthcare
system, inquiring about religious and spiritual beliefs, acknowledging cultural differ-
ences, seeking consultation to aid in culturally adapted care, reducing stigma of
mental health treatment, and involving family in care.

Medication
Psychological interventions should be administered in conjunction with antipsychotic
medication for maximum benefit, at least during acute phases of illness. However,
benefits and side effects of medication should be considered when choosing an
antipsychotic, such as metabolic, extrapyramidal, cardiovascular, hormonal, and
other concerns (NICE, 2014). Due to factors such as poor treatment response,
intolerable side effects, and comorbid substance misuse, medication nonadherence
in schizophrenia has been estimated at a rate of almost 50% (Lacro et al., 2002).
Further, treatment-resistance to antipsychotic medication is a considerable problem
(Howes et al., 2017), in which case psychosocial interventions such as CBT and
family intervention are recommended (NICE, 2014).

Conclusion
Schizophrenia and related psychotic disorders are impairing and challenging condi-
tions to treat. They negatively impact patients, their families, and the larger society.
Fortunately, science offers various empirically supported treatment options to help
those with psychosis that have been shown to decrease symptoms and impairment. In
this chapter, we described several psychological therapies that have been demon-
strated to improve outcomes for individuals with psychosis beyond medications
alone. We also detailed credible and efficacious treatment components found across
these interventions. Unfortunately, many individuals are not given the opportunity to
receive empirically supported psychosocial treatment for psychosis. It will take
a concerted effort on the part of mental health and medical professionals, policy
makers, and the public to improve the dissemination and implementation of science-
backed treatments for psychosis so that individuals with psychosis are given the best
chances of achieving the long-term recovery that they deserve. We hope that this
chapter will contribute to that aspirational goal.
296 Thompson, Visser, Ward, and Gaudiano

Useful Resources

Treatment Manuals
• Assertive Community Treatment (ACT): Evidence-Based Practices (EBP) KIT: https://
store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-
Practices-EBP-KIT/SMA08-4344
• Landa, Y. (2017). Cognitive behavioral therapy for psychosis (CBTp): An introductory
manual for clinicians. Mental Illness Research, Education & Clinical Center. www.mirecc
.va.gov/visn2/docs/CBTp_Manual_VA_Yulia_Landa_2017.pdf

Journals
• Psychosis: Psychological, Social and Integrative Approaches: www.tandfonline.com/journals/
rpsy20
• Schizophrenia Bulletin: https://academic.oup.com/schizophreniabulletin

Organizations
• Hearing Voices Network: www.hearing-voices.org/
• Schizophrenia International Research Society: https://schizophreniaresearchsociety.org/

Clinical Practice Guidelines

• Addington, J., Addington, D., Abidi, S., Raedler, T., & Remington, G. (2017). Canadian
treatment guidelines for individuals at clinical high risk of psychosis. Canadian Journal of
Psychiatry, 62, 656–661. https://doi.org/10.1177/0706743717719895
• Keepers, G. A., Fochtmann, L. J., Anzia, J. M., et al. (2020). The American Psychiatric
Association practice guideline for the treatment of patients with schizophrenia. American
Journal of Psychiatry, 177, 868–872. https://doi.org/10.1176/appi.ajp.2020.177901

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 17
Autism Spectrum and Intellectual Developmental Disorder
Frank R. Cicero

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by

issues with social communication and idiosyncratic behavior. Formal diagnosis in the
United States is made through diagnostic criteria as per the Diagnostic and Statistical
Manual of Mental Disorders: Fifth Edition (DSM-5-TR; American Psychological
Association [APA], 2022). In order to receive a diagnosis, individuals must display
a range of deficits affecting the ability to socialize with others. This includes both
verbal and nonverbal behaviors used to communicate with others in a social setting
(APA, 2022). Individuals must also engage in a range of restricted and repetitive
behaviors across multiple settings. This can include behaviors such as maintaining
routines, sensory stimulation, motor movements, verbal perseveration, and fixed
interests (APA, 2022). In order to formally give a diagnosis, these characteristics of
autism must be noted in the early developmental period.
ASD has formally been considered a spectrum disorder since the publication of
the DSM-5 in 2013. As a spectrum, a range of affectedness is noted across persons
when it comes to behavior severity, communication deficits, and cognitive ability
(Steinbrenner et al., 2020). Although usually diagnosed in childhood, autism will
affect an individual across the lifespan. Epidemiological data indicate global preva-
lence rates for ASD ranging from 0.7% to 2.6% of the childhood population (Lyall
et al., 2017), with the current estimate in the United States standing at 2.3% of eight-
year-olds (Maenner et al., 2021). Studies investigating the population rates for ASD in
adulthood are limited. The most current studies indicate prevalence estimates ranging
from 1.1% of the adult population in England (Brugha et al., 2016) to 2.2% of the
adult population in the United States (Dietz et al., 2020). Although we do not have
definitive epidemiological data, research indicates that the number of adults with ASD
is increasing over the years (Laugeson et al., 2015).
Intellectual developmental disorder (IDD) is a condition most characterized by
clinically significant deficits in cognitive abilities and adaptive functioning. As with
ASD, a formal diagnosis of IDD in the United States is made through diagnostic
criteria as per the DSM-5-TR. According to the criteria, individuals must display
304
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significant deficits in cognitive functioning as measured through a standardized

assessment of intellectual abilities. Typically, derived scores must fall approximately
two standard deviations below the population mean (APA, 2022). Individuals must
also display significant limitations in adaptive behavior as compared to culturally
appropriate standards. Adaptive deficits must be displayed across various areas
including communication skills, social skills, personal independence, and/or school/
work functioning. Symptoms of IDD must manifest in the developmental period and
will show lifelong effects on skills and behavior (McKenzie et al., 2016). The global
prevalence rate of IDD is reported to be approximately 1% of the population;
however, estimates vary widely due to methodological differences across studies
(McKenzie et al., 2016). Prevalence rates are also difficult to determine due to
comorbidity with other developmental conditions (i.e., ASD) and the presence of
diagnostic overlap leading to misdiagnosis (Pedersen et al., 2017). Within the diag-
nosis of IDD, the DSM-5-TR indicates levels of severity as mild, moderate, severe,
and profound. Classifications of level are made based on the severity of cognitive and
adaptive skill deficits displayed by an individual. Prevalence of severe IDD in the
general population falls at approximately 0.6%, or 6 out of 1,000 persons (Saad &
ElAdl, 2019).

Etiology and Theoretical Underpinnings of Treatment

ASD is a complex condition with differing forms of behavioral and cognitive
expression. Therefore, it is likely that various causes contribute to its development.
At the present time, there are no definitive risk factors, simple etiological explan-
ations, or genetic markers for a diagnosis of ASD (Yoon et al., 2020). The current
theory is that the condition is a result of a combination of genetic, prenatal environ-
mental, and epigenic factors (Yoon et al., 2020) with genetic factors likely exerting
more influence than environmental factors (Bailey et al., 1995). With regard to IDD,
etiology of the condition varies according to the specific diagnosis. Causal factors are
never discovered for at least 50% of cases of mild IDD, whereas definitive biological
causes are noted for at least 75% of cases of severe IDD (Patel et al., 2018). Results of
a recent systematic review implicated ten prenatal factors correlated with IDD,
including variables such as maternal age, maternal alcohol use, maternal tobacco
use, and maternal health issues such as hypertension and epilepsy. Preterm birth and
low birth weight were also found to be correlates (Huang et al., 2016).
Interventions for ASD are generally separated into two categories: comprehensive
and focused treatment models (Steinbrenner et al., 2020). In a comprehensive treat-
ment model, the goal of intervention is to have a broad positive impact on the core
deficits of ASD through the use of a structured set of practices following one
conceptual philosophy of therapy (Wong et al., 2015). Two examples of comprehen-
sive treatments are the Early Intensive Behavioral Intervention (EIBI) program of
306 Frank R. Cicero

Lovaas and colleagues (e.g., Lovaas, 1987; Smith & Lovaas, 1998) and the TEACCH
program by Schopler and colleagues (1995). Focused treatments, on the other hand,
are designed to treat only a single skill or behavior rather than being considered
a global treatment for ASD (Steinbrenner et al., 2020). They are often considered the
discrete interventions that, when put together, make up comprehensive treatments
(Wong et al., 2015). Interventions for adults with IDD can break down in a similar
fashion.
When it comes to establishing evidence-based practice for either comprehensive
or focused interventions for adults, the problem is that the majority of treatment
research has been conducted only with children. In their review of 150 autism
intervention studies, Seaman and Cannella-Malone (2016) found that 63% were
conducted with participants aged eight years of age or less, and only 2% with
participants aged 20 or older. Recent task forces investigating evidence-based prac-
tices for ASD treatment in children have indicated 28 practices that meet criteria
(Hume et al., 2021). The definitions and procedures for establishing evidence-based
practice vary by discipline and by evaluator. Some procedures, such as those outlined
by Schalock and colleagues, which were described for use with treatments for IDD,
are relatively broad. According to the authors, evidence-based practice is defined as
“practices for which there is a demonstrated relation between specific practices and
measured outcomes” (Schalock et al., 2017, p. 115). Operational definitions are
provided for the terms “evidence,” “practices,” and “demonstrated relation.”
A more quantitative and objective method of establishing evidence-based practice
for treatments of ASD was explained by Reichow (2011). In his method, Reichow
establishes three formulas/rubrics for evaluating evidence-based practice: one for
evaluating research report rigor, one for determining research report strength, and
finally a quantitative formula used for evaluating if a treatment has enough research to
be considered evidence-based. In their task force report, Hume et al. (2021) relied on
several evidence-based practice procedures, including a method outlined by Horner
and colleagues (2005) which was specifically designed to identify evidence-based
practice through single-subject design research. Similar to Reichow (2011), Horner
and colleagues’ method uses a rubric of quality indicators and a formula across studies
to determine if a specific treatment can be considered evidence-based.
The majority of evidence-based practices for ASD treatment follow applied behav-
ior analytic methodology and philosophy (Steinbrenner et al., 2020). In fact, one of
the most effective comprehensive treatments for children with ASD has been found
to be the EIBI program (Wong et al., 2015). Although we have considerable data
supporting evidence-based practice with children, we cannot be sure that those same
practices would be effective with adults with ASD. High-quality treatment research of
psychosocial interventions with adults with ASD is lacking and those studies that are
published tend not to focus on the core symptoms of ASD or use outcome measures
designed for different populations or purposes (Brugha et al., 2015; Eack et al., 2018).
 Autism and Intellectual Developmental Disorder 307

Unfortunately, many studies with adults with ASD do not provide outcome evidence
of globally significant change, such as measures of overall mental health and quality
of life (Lorenc et al., 2018).
There are also issues with establishing evidence-based practice in the treat-
ment of behaviors and characteristics associated with IDD. Treatment studies in
IDD often have inadequate numbers of participants, rely on poor research
designs, lack control groups, and report different outcome measures between
studies (Bhaumik et al., 2011). Because of this, treatments for IDD populations
are often based on research conducted with neurotypical populations with mental
health issues (Bhaumik et al., 2011). This generalization, however, may not be
appropriate.

Brief Overview of Treatments

Recent task force data indicate that, at this time, 28 intervention practices have met
criteria to be considered evidence-based practice for use with children with ASD
(Hume et al., 2021; Steinbrenner et al., 2020). Unfortunately, research with adults
with ASD remains weak and therefore specific evidence-based practices to use with
adults with ASD have not yet been established (Howlin & Moss, 2012). The majority
of the intervention strategies commonly employed with adults with ASD and IDD
broadly fall into the category of applied behavior analytic interventions (Steinbrenner
et al., 2020).
In its most general definition, applied behavior analysis (ABA) is the science of
learning. It employs the principles of learning theory, including such concepts as
reinforcement, shaping, chaining, punishment, and motivation, to increase socially
significant behavior in clients (Cooper et al., 2020). In this way, the principles and
procedures of ABA form the foundation for behavior therapy, an evidence-based
practice. For a much more comprehensive and detailed review of ABA, the reader is
referred to comprehensive texts such as Cooper et al. (2020) and Vargas (2020). Roth
et al. (2014) conducted a meta-analysis of the literature on behavioral interventions
used with adults with ASD. Out of 43 qualifying studies, strong positive effects were
obtained for behavioral interventions used to increase academic skills (nonoverlap of
all pairs [NAP] effect sizes ranging from 83.24 to 100), decrease phobic avoidance
behaviors (NAP score of 100), and increase vocational skills (NAP scores ranging
from 85.09 to 100). Medium effect sizes were noted for interventions addressing
adaptive living skills (NAP scores ranging from 65.7 to 100), problem behavior (NAP
scores ranging from 76.9 to 95), and social skills (NAP scores ranging from 59.9 to
100). True efficacy was difficult to determine, however, because 77% of the reviewed
studies lacked a treatment integrity measure. This means it could not be determined
whether the behavioral interventions were implemented as described. The specific
behavioral interventions that showed efficacy included behavioral skills training, task
308 Frank R. Cicero

Box 17.1 Co-occurring Mental Health Conditions

Research indicates that adults with ASD and/or IDD are at an elevated risk of being
diagnosed with co-occurring mental health conditions (Evans & Randle-Phillips, 2020;
Hollocks et al., 2019; Lai et al., 2019). Prevalence estimates are difficult to determine and
vary across studies (Levy & Perry, 2011); however it has been found that up to 70% of
adults with ASD have a comorbid mental health diagnosis and over 40% have multiple
comorbid mental health diagnoses (Lai et al., 2019). The prevalence of co-occurring
mental health issues in IDD is estimated to be at 10–40% (Evans & Randle-Phillips,
2020). Co-occurring mental health issues are typically diagnosed early in adulthood, with
the majority of mental health issues in adults with ASD diagnosed before age 30 (Levy &
Perry, 2011). It is difficult to estimate the prevalence of co-occurring conditions because
reports of behavioral changes are usually made by third parties instead of the person
(Levy & Perry, 2011) and ASD characteristics can overshadow symptoms of other mental
health conditions (Hollocks et al., 2019; Lai et al., 2019).
Out of all co-occurring mental health conditions, anxiety conditions, depression, and
attention deficits show the highest rates of comorbidity with ASD in adults. In their
systematic review, Hollocks et al. (2019) found that adults with ASD in their selected
studies showed high comorbidities with anxiety disorders (27% current prevalence, 42%
lifetime prevalence), depression (23% current prevalence, 37% lifetime), social anxiety
(29% current prevalence, 20% lifetime), and obsessive-compulsive disorder (24% current
prevalence, 22% lifetime). As a comparison, prevalence rates for anxiety conditions in the
general population range from 1--12%, and for depression rates are reported to be
approximately 7% of the general population (Hollocks et al., 2019). Attention-deficit
/hyperactivity disorder has been found to the be most frequently occurring co-diagnosis in
adults with ASD (Lugo-Marin et al., 2019). Elevations have also been seen with co-
occurring Tourette’s syndrome, epilepsy, bipolar disorder, and schizophrenia (Levy &
Perry, 2011; Lai et al., 2019). Given the effects of diagnostic overshadowing and issues
with third-party reporting of thoughts, feelings, and behaviors it is possible that these
reported comorbidity prevalence rates are lower than the actual rates.
It is highly important to recognize and treat co-occurring mental health issues in adults
with ASD and IDD. Higher than typical rates of co-occurring diagnoses may be the result of
genetic vulnerabilities resulting from or correlating with their developmental disabilities,
increased frequency of negative life events, increased exposure to abuse, awareness of
their disability and how it affects their quality of life and social relationships, increased
frequency of bullying in childhood, rejection from peers, and social communication deficits
(Evans & Randle-Phillips, 2020; Lugo-Marin et al., 2019; Wigham et al., 2017). Left
untreated, co-occurring mental health conditions lead to worsened long-term outcomes
for adults with ASD. Co-occurring attention-deficit/hyperactivity disorder has been linked to
increased impairments in adaptive living skills; co-occurring anxiety has been correlated
with an exacerbation of ASD symptoms; and co-occurring depression has been associated
with the presence of aggressive behavior, self injury, and oppositional behavior in adults
with ASD (Lai et al., 2019). Activities of daily living such as eating, sleeping, and socialization
can also be affected (Lugo-Marin et al., 2019). Frequent screening for mental health issues
in adults with ASD and IDD as part of ongoing treatment is indicated.
 Autism and Intellectual Developmental Disorder 309

analyses, prompting, video modeling, differential reinforcement, and role playing.

NAP effect sizes ranged from 91.35 to 93.37, supporting efficacy (Roth et al., 2014).
Research has shown that adults with developmental disabilities, including IDD and
ASD, display decreases in problem behavior and increases in reported quality of life
when treated with behavioral interventions that are often incorporated into ABA
(Gregori et al., 2020). As described in the next section, these interventions include
behavioral skills training, video modeling, role playing, task analysis, prompting,
differential reinforcing, and functional communication training. Other evidence-
based practices, also described in the next section, include cognitive-behavioral
therapy, social skills interventions, employment-based interventions, educational
practices, and other psychosocial techniques (i.e., mindfulness therapies).

Credible Components of Treatments

Applied Behavior Analysis
Behavioral Skills Training
Behavioral skills training (BST) is an evidence-based behavioral teaching procedure
consisting of four components: instructions, modeling, rehearsal, and feedback
(Nuernberger et al., 2013). Training sessions start off by providing learners with
clear instructions on the target behavior that they are expected to perform in a given
situation. Instructions can be written, verbal, visual, or a combination of modalities.
Instructors then provide a model of what is expected. This is followed by having the
learners practice what was modeled while feedback is given by instructors. This is
repeated until the skill is mastered under training conditions and then generalized to
naturally occurring conditions. Nuernberger et al. (2013) demonstrated the effective-
ness of BST by teaching three young adults with ASD to improve their social
conversation skills. BST sessions were conducted for 10 minutes each session, 1–5
times per day over a 4-week period. Gains in conversation skills were still maintained
8 weeks post-training with BST. In a systematic review of BST literature related to
skill acquisition in autistic children, Lucchesi (2022) found 24 studies that met her
predetermined inclusion criteria. Using procedures from Reichow (2011), results
indicated that BST reached the level of evidence-based practice for use with autistic
children to teach skills including abduction prevention, gun safety, poison safety,
street crossing, seeking help when lost, conversation skills, sports skills, daily living
skills, and academics.

Video Modeling
Video modeling is an instructional procedure whereby learners are required to watch
a video demonstrating a model engaging in a target behavior in a given situation. After
video exposure, the learner is asked to perform the target skill under a simulated or
310 Frank R. Cicero

real-life condition. Feedback on performance is given by the instructor and the entire
procedure can be repeated as needed until the skill is mastered. Videos can depict the
learner themselves engaging in the target behavior (self as model) or others engaging
in the target behavior (other as model) (Park et al., 2019). Video modeling procedures
have been used to teach a wide variety of target behaviors to children and adults with
ASD and/or IDD. Bross et al. (2021) conducted a meta-analysis of video modeling
with regard to interventions to improve job-related skills in autistic adults. In their
review, 11 single-subject research studies met their inclusion criteria and were
determined to be methodologically sound. To analyze effectiveness, 66 effect sizes
were calculated from the data of 33 participants. Tau-U analyses were used to assess
effect size. Across all 11 studies, an omnibus Tau-U of 0.91 (range 0.84–0.97) was
obtained, indicating a very large magnitude of change across targets. Job-related
targets included a variety of skills including, but not limited to, clerical activities,
gardening, and food preparation. One relevant finding with regard to moderating
variables is that effect sizes were found to be higher for ASD participants who did not
have a comorbid diagnosis of IDD (Bross et al., 2021).

Role Playing
Role playing is a procedure whereby a learner is asked to perform a target skill,
according to a pre-introduced script, within a simulated setting including actors
playing the roles of persons within those settings. Feedback is provided by instructors
either during or after the role play, and role plays continue until the skill is mastered in
the simulated setting. The target behavior is then generalized to naturally occurring
conditions. Role playing is often used as one of the components of BST. For example,
through role playing within a BST intervention, Fisher et al. (2013) successfully
taught five young adults with IDD to avoid lures from strangers by engaging in
appropriate verbal and physical responses when approached. In their meta-analysis
of safety skills interventions for children and adults with ASD, Wiseman et al. (2017)
compared effect sizes across studies utilizing four different interventions: video
modeling with or without rehearsal, live modeling with or without rehearsal, role
play, and single error corrections procedure. The highest average Tau-U scores (all
indicating large effect sizes) were obtained for studies utilizing role play as compared
to other interventions.

Task Analysis
Task analysis is a breakdown of a complex task into its component parts. Component
parts are taught individually and then linked together by behavioral chaining proced-
ures so that the learner eventually masters the entire complex task (Cooper et al.,
2020). In treatment, task analyses are often used in combination with other teaching
techniques, such as video modeling, video prompting, differential reinforcement, and
 Autism and Intellectual Developmental Disorder 311

chaining. Task analyses have been shown to be an efficacious component of effective

interventions in the teaching of a wide variety of skills in adults with ASD and/or IDD,
including vocational skills, leisure skills, and activities of daily living (Roth et al.,
2014). In their 2014 meta-analysis, Roth et al. reviewed outcome data for nine studies
that included a task analysis as a treatment component. Eight of the nine studies had
a level of research rigor to be considered “conclusive certainty of evidence” and had
NAP effect size scores ranging from 86.4 to 100. Task analysis was also determined
to be an evidence-based practice for children and adults with ASD according to
a systematic review conducted by Hume et al. (2021). In their review, the authors
found 13 single-subject design studies that met predetermined inclusion criteria,
published between 1990 and 2017, that supported the use of interventions including
task analysis as a component. Although rising to the level of evidence-based practice
as per Hume et al. (2021) and Roth et al. (2014), it is important to note that task
analysis is not a treatment by itself, but rather an efficacious component of treatment
packages consisting of additional teaching techniques (i.e., video modeling, chaining,
prompting, etc.)

Prompting
Prompting refers to the use of physical, gestural, verbal, or other forms of cues to
guide a learner to engage in a correct response. As with task analyses, prompting is
often used in combination with other behavioral teaching techniques and can be
implemented in a least-to-most or most-to-least format with regard to intrusiveness
level (Cooper et al., 2020). For example, a skill may be taught through gradually
increasing the prompt level as needed from unintrusive verbal prompts (telling an
individual how to do something) and modeling prompts (showing an individual how
to do something) to more intrusive prompts such as full physical prompts (guiding an
individual through a task using hand-over-hand physical manipulation). However, to
best foster independence in a skill, an instructor may choose to gradually reduce the
intrusiveness of the prompt level, starting off by ensuring a correct response with the
most intrusive prompting level (i.e., full physical prompt), then reducing to a less
intrusive prompt (i.e., gestural prompt), and ultimately fading the need for all prompts
(independence).
Prompting has been used across a wide range of skill areas with both autistic adults
and adults with intellectual deficits. Nepo et al. (2021) used a most-to-least prompt
hierarchy to promote independent leisure engagement with an iPad in six adults with
IDD and ASD between 34 and 45 years of age. Treatment consisted of prompting
starting with full physical prompts, fading to gestural prompts, then to verbal prompts,
and finally to independence without prompts. Verbal praise and tangible reinforce-
ment were delivered contingent on independent completion of a skill. The
research was conducted using a multiple-probe across participants, single-subject
312 Frank R. Cicero

experimental design. Results showed attainment of skill independence for all partici-
pants as well as an increase in duration of leisure engagement (Nepo et al., 2021). In
another example of the use of prompting, Vedora and Conant (2015) used both echoic
prompts (verbal imitation) and textual prompts (written words) in the teaching of
social question answering to three autistic young adults. Prompting was used along
with verbal praise and edible reinforcement for correct responding. Results of an
alternating treatments single-subject design indicated that both forms of prompting
(echoic and textual) were successful in promoting independent question answering;
however, the form that was most effective was individualized between participants
(Vedora & Conant, 2015).

Differential Reinforcement
Differential reinforcement refers to a broad range of interventions in which reinforce-
ment is provided for some behaviors, often within the same response class, while
reinforcement is withheld for other behaviors (Cooper et al., 2020). Differential
reinforcement procedures can be used to systematically increase or decrease target
behaviors depending on which behaviors receive reinforcement (Cooper et al., 2020).
For example, May and Catrone (2021) successfully taught three adults with Down
Syndrome to reduce their pace of eating by using a differential reinforcement of low
rate behavior reinforcement schedule. Participants were presented with a meal and
a timer was used to identify inter-response times that would result in reinforcement. If
a bite of food was taken after a predetermined interval, that response resulted in verbal
praise. Tokens to be exchanged for preferred reinforcers were also provided contin-
gent on successful inter-response times. Tokens were not provided when bites were
taken before target inter-response times. Data, collected within a combination chan-
ging criterion and reversal design, showed improvement for all three participants.
Differential reinforcement procedures can be implemented in isolation or can be
included within part of a more comprehensive behavior intervention program. In
their systematic review of differential reinforcement procedures, implemented with-
out extinction, in the treatment of problem behavior in autistic adults, MacNaul and
Neely (2018) reviewed 10 studies that met predetermined inclusion criteria. Out of the
10 studies, 9 were determined to show conclusive evidence as assessed by quality of
research rigor and Tau-U effect sizes ranging from large (seven analyses), to medium
(five analyses), to small (four analyses).

Functional Communication Training

Functional Communication Training (FCT) is another behavioral strategy that has
shown to be an effective intervention for adults with autism and/or IDD. In an FCT
intervention, a target challenging behavior is decreased through an assessment of the
behavior’s function followed by the introduction of a communication response that
 Autism and Intellectual Developmental Disorder 313

the learner can use in place of the target challenging behavior in order to get their
wants and needs met. The new communicative response, which can be verbal, visual
through pictures, electronically spoken, manually signed, and so forth, is taught
through a differential reinforcement procedure (Cooper et al., 2020). In their system-
atic review of FCT intervention studies used with adults with ASD, Gregori et al.
(2020) found that all reviewed studies demonstrated moderate or strong evidence of
effectiveness. Decreases in targets were noted across a diverse group of participants
and for a wide range of challenging behaviors.

Cognitive-Behavioral Therapy
In broad terms, cognitive-behavioral therapy is a short term, goal-oriented psycho-
therapy used to encourage change in the thought patterns and behaviors of individuals
(Spain et al., 2015). The primary goal of CBT is to have a client understand the
interrelation of their thoughts, behaviors, and emotions so that they can develop new
ways of thinking about, coping with, and responding to challenging situations that
they encounter (Spain et al., 2015). Falling into the realm of a talk therapy (Spain
et al., 2015), effectively employing CBT techniques with individuals with challenges
in communication and introspection (i.e., adults with ASD and/or IDD) can be
problematic. Research indicates, however, that CBT may be appropriately used
with adults with ASD if what is emphasized during therapy sessions is the develop-
ment of behavioral coping and social strategies (Kiep et al., 2015). CBT has been
shown to be effective in the treatment of obsessive-compulsive disorder comorbid
with ASD in adults in both the short term and at 12-month follow up (Russell et al.,
2013). In their systematic review of CBT and adults with ASD, Spain et al. (2015)
found decreases in comorbid mental health symptoms in all reviewed studies. Six
studies met the authors’ predetermined inclusion criteria. Of these studies, two were
randomized control trials, one was a quasi-experimental study, one was a group-based
case series intervention, and the remaining two were case studies. All six studies
passed a quality review before data were extracted for analysis. Interventions included
in the studies consisted of various forms of CBT, such as exposure-based therapy,
relaxation techniques, distraction techniques, restructuring of thoughts and beliefs,
and psycho education. It is important, however, to note that some modifications to
standard procedures were reported in order to effectively implement CBT procedures
with autistic participants.
Due to communication deficits, introspection difficulties, theory of mind deficits,
issues with cognitive flexibility, and weak central coherence, Spain et al. (2015)
outlined modifications to traditional CBT procedures that may increase its effective-
ness for adults with ASD. Suggested modifications include (1) using written and
picture cues to enhance discussion and recall, (2) individualizing descriptions of
emotions, (3) individualizing outcome measures, (4) teaching emotional literacy
314 Frank R. Cicero

prior to initiating CBT, (5) emphasizing behavior change and skill development, and
(6) relying less on a “talk therapy” style of sessions (Spain et al., 2015). These
adaptations may also be useful when using CBT or other forms of talk therapy with
individuals with IDD without ASD. There are also often difficulties with applying
what is learned in therapy sessions to everyday situations, completing homework
assignments, and in maintaining change over time (Evans & Randle-Phillips, 2020).
Including family members and/or support workers in psychotherapy sessions may
prove beneficial for these reasons.

Mindfulness-Based Therapy
Mindfulness interventions have been shown to improve mental health and wellness in
adults both with and without ASD (Hartley et al., 2019). Effects have been displayed
across a variety of physical and psychological conditions (Sizoo & Kuiper, 2017). In
2005, Kabat-Zinn defined mindfulness as the conscious awareness of oneself that
arises by focusing thoughts and attention only on environmental stimuli that are
present in the moment without judgment (Sizoo & Kuiper, 2017). The ability to
engage in mindful thought is gained by working with a therapist on attention exercises
within MBT sessions and practicing mindfulness outside of sessions through home-
work assignments (Sizoo & Kuiper, 2017). There are various forms of MBT that are
seen in the literature with ASD; two examples are mindfulness-based stress reduction
(MBSR) and mindfulness-based cognitive therapy (MBCT). In MBSR, symptoms of
stress and anxiety are treated through procedures such as breathing exercises, medita-
tion, identifying physical reactions to stress, listening exercises, dealing with persist-
ent negative thoughts, and so forth. Therapists assist clients in implementing these
procedures through structured therapy sessions, often scheduled once per week, in
addition to homework assignments for practice outside of sessions. MBCT includes
both the procedures used in MBSR along with the theories, procedures, and goals of
traditional CBT (Hartley et al., 2019; Sizoo & Kuiper, 2017).
In their review of 10 independent studies in which MBT was used with children and
adults with ASD, Hartley et al. (2019) found preliminary evidence to support its use
with this population. Both short- and long-term improvements in measures of sub-
jective well-being were obtained in the studies; however, effects on specific symp-
toms of ASD or mental health were not reported. Similar conclusions were reported
by Cachia et al. (2016) in their systematic review of MBT in children and adults with
ASD with and without IDD. Data from 161 participants across six studies that met
inclusion criteria and quality review were analyzed. Of those 161 participants, 91
were adults. Results of the systematic review indicated that MBT is a potentially
effective intervention that promotes psychological well-being in adults with ASD,
including decreases in symptoms of anxiety, depression, and rumination along with
increases in positive affect (Cachia et al., 2016). Kiep et al. (2015) employed MBT
 Autism and Intellectual Developmental Disorder 315

with 50 adults with ASD without IDD with the goal of treating symptoms of depres-
sion, anxiety, and rumination. A modified MBT protocol was utilized in order to
increase the effectiveness of MBT procedures with an ASD population. Specifically,
a focus on one’s own thoughts was eliminated, metaphors and ambiguous terms were
avoided, the length of treatment was extended by one week, and breathing exercises
were extended from 3 to 5 minutes. The study consisted of 9 weekly sessions, of
2.5 hours each plus 40–60 minutes of at-home practice 6 days a week. Results
indicated improvements in symptoms of anxiety, depression, agoraphobia, somatiza-
tion, sleeping problems, rumination, positive affect, and measures of general physical
and psychological well-being (Kiep et al., 2015). Future research on MBT should
investigate the effects of MBT on specific mental health symptoms as well as on the
core deficits of ASD through objective observation of behavior. The effectiveness of
procedures when used with individuals with and without IDD should be explored so
that modified protocols can be standardized as needed. Studies need to be designed
and implemented with stronger research rigor so that the evidence-base of the effects
of MBT with adults with ASD and/or IDD can be properly investigated.

Social Skills Interventions

Despite improvements in many areas over the course of development and educa-
tion, adults with ASD often continue to struggle with social relationships and social
competence. Social competence is a complex construct that refers to the ability to
use social behaviors to successfully form relationships and achieve desired social
goals while ensuring that behaviors are appropriate given ever-changing contexts
(Ke et al., 2018). Interventions targeting social skills may improve outcomes for
adults with ASD related to social-communication behaviors and increase engage-
ment in social activities (Lorenc et al., 2018). Unfortunately, there are not many
packaged social skills interventions that have reached the status of evidence-based
practice for use with adults with ASD (Laugeson et al., 2015). Social skills training
is typically conducted in group settings and relies on behavioral strategies based on
social learning theory to shape new social behaviors in learners (Dubreucq et al.,
2022). Specific treatment strategies often include goal setting, role modeling,
behavioral rehearsal, positive reinforcement, corrective feedback, and homework
assignments to promote generalization (Dubreucq et al., 2022). In their meta-
analysis of 18 studies in which social skills training was implemented with adults
with ASD without IDD, Dubreucq and colleagues (2022) found that individuals
who received social skills training improved more on measures of social respon-
siveness than individuals who did not receive training. Of the 18 studies, four
employed modified PEERS (Program for the Education and Enrichment of
Relational Skills) interventions, two focused on social skills in vocational settings,
and the remainder were individualized interventions using a variety of techniques
316 Frank R. Cicero

and targets. The results of the meta-analysis reflected the treatment data of 145
adult participants with ASD. A positive effect size of 0.93 was obtained using
a forest plot analysis of parent-reported social responsiveness after treatment. One
caveat to note, however, is that the majority of included studies were found to be
below accepted standards of research rigor. Studies were found to have small
sample sizes, issues with randomization, missing comparison groups, and group
allocation masking. The authors further suggested that the effects of social skills
training may be enhanced if the training is conducted in contexts that facilitate
practice: for example, directly in an office setting with coworkers if the treatment
was designed to shape social skills in vocational settings, or in a park if the
treatment was designed to shape social skills in a less structured setting.
Although it is unlikely that any one social skills intervention strategy will show
effectiveness with all adults with ASD (Ke et al., 2018), the PEERS program is
showing some positive results (Laugeson et al., 2015). Originally developed for
children aged 11–16 on the ASD spectrum, PEERS® is a small-group social skills
intervention utilizing a combination of didactic lessons, role plays, behavioral
rehearsal, coaching, parent facilitators, and homework assignments (McVey
et al., 2016). Since 2009, research has shown the program to be efficacious with
children with ASD (Gantman et al., 2012). The program focuses on the improve-
ment of social skills associated with the making and maintenance of friendships.
Specific skills taught in the PEERS® program include conversation, peer entry and
exit, developing friendship networks, teasing, bullying, arguments, good sports-
manship, host behavior, and changing a bad reputation (McVey et al., 2016). The
program has since been adapted for a young adult population. In their adaptation,
Gantman and colleagues (2012) maintained the majority of the original PEERS®
content and methods; however, some topics that were deemed not necessary for
adult learners were removed, and other topics that were not in the children’s version
were added. Modules that were added included lessons on dating etiquette and
handling peer pressure. Self-derived goals were used to increase motivation and
treatment compliance. The PEERS® for Young Adults program, which has now
been manualized, has shown efficacy with improving overall social skills in young
adults, including increases in social responsiveness, increases in the frequency of
social get-togethers, increases in social skills knowledge, and reported decreases in
loneliness, restricted interests, and repetitive behaviors. These effects were demon-
strated through independent randomized controlled trials (Gantman et al., 2012;
Laugeson et al., 2015; McVey et al., 2016). Due to some limitations in the studies
(e.g., lack of ASD-specific standardized outcome measures, lack of third-party
raters, reliance on self-report measures, and small sample sizes), further research
is required before the PEERS® for Young Adults can be considered an evidence-
based practice; however, treatment results so far seem promising.
 Autism and Intellectual Developmental Disorder 317

Employment-Related Interventions
Successfully maintained full- or part-time employment is often a primary goal of
education and therapy. Unfortunately, data indicate that employment rates for adults
with ASD and/or IDD are significantly less than for neurotypical adults and for adults
with other developmental diagnoses (Almalky, 2020). Higher rates of unemployment
in ASD, as compared to adults in other disability groups, have been found in the
United States, the United Kingdom, Australia, and Canada (Hedley et al., 2017).
Employment rates for adults with ASD vary between 10–50% (Nicholas et al., 2015)
with between 50–70% of adults with ASD being unemployed (Jacob et al., 2015).
Research data indicate that only 39% of adults with IDD are competitively employed
eight years after high school graduation (Almalky, 2020). When employed, adults
with ASD and/or IDD often work for significantly less pay and work fewer hours than
do other adults (Nicholas et al., 2015; Almalky, 2020). Jobs are often held in
occupations such as food preparation, cleaning, and maintenance, regardless of
cognitive level (Seaman & Cannella-Malone, 2016). Including “underemployment,”
it is estimated that 90% of adults with ASD are not fully employed to their potential
(Walsh et al., 2017).
These statistics are particularly alarming given the benefits to psychological and
emotional well-being that being employed provides. Competitive employment allows
an individual to be less dependent on others, increases friendships, boosts self-esteem,
and improves overall quality of life (Nicholas et al., 2015). Employment has been
found to correlate with an increased sense of purpose, meaning, independence, and
identity for individuals with ASD (Jacob et al., 2015). Adults with IDD have reported
that being gainfully employed reduces negative feelings associated with being dis-
abled (Almalky, 2020).
Comprehensive employment training programs for adults with ASD and/or IDD
are often separated into three general categories; sheltered workshop employment,
supported employment, and customized employment. In a sheltered workshop model,
individuals are placed in a segregated setting, often with a large number of individuals
all working on similar tasks and all with similar developmental diagnoses. There are
two types of sheltered workshop models. In a transitional sheltered workshop,
employees of the workshop are expected to be there for only the length of time it
takes to master skills needed for competitive employment in the community.
Extended sheltered workshops, on the other hand, are more long-term employment
placements (Almalky, 2020). In a supported employment model, a trained job coach is
used to maintain an individual within a community-based job setting (Nicholas et al.,
2015). Customized employment is a form of supported employment designed for
adults who require additional individualization tailored to a person’s strengths,
interests, and preferences (Wehman et al., 2018). Both forms of integrated employ-
ment models – supported employment and customized employment – consist of four
318 Frank R. Cicero

phases: (1) becoming familiar with the client, (2) matching the client to an appropriate
job, (3) providing on-the-job training and support, and (4) job retention services
(Wehman et al., 2018).
Although research studies are often limited by small participant numbers and
vague outcome measures (Nicholas et al., 2015), there is evidence that indicates
better outcomes for supported employment models over sheltered workshop
models. With supported employment, adults with ASD were more likely to secure
a job, to get a job with a higher salary, and to be able to choose from a wider variety
of jobs than were adults who did not enroll in a supported employment program
(Nicholas et al., 2015; Hedley et al., 2017). Although one purported purpose of the
transitional sheltered workshop model is the ability to teach people skills needed to
transition into community-based job settings, data indicate that there is no differ-
ence in employment outcome based on whether or not a person was first instructed in
a sheltered workshop (Almalky, 2020). Customized employment has been found to
result in employment positions with 30% more work hours per week and three times
the amount of pay as compared to sheltered workshop outcomes (Almalky, 2020).
Although supported employment programs are efficacious, there are, unfortunately,
three times as many adults with ASD in sheltered workshops than in supported
employment programs (Hedley et al., 2017).
One issue with the integrated employment models is the amount of training and
expertise that is required. Agencies and staff must know how to assess learner
choice, arrange for funding, identify potential jobs in the community, interact
with parents, approach potential employers, help secure Social Security income
benefit determinations, arrange transportation to and from job sites, and effectively
train learners on all necessary job skills (Wehman et al., 2018). The success of
supported employment programs relies on the skills of job coaches at both finding/
securing job placement and in providing one-on-one evidence-based training on the
jobsite (Nicholas et al., 2015). With their focus on individualization, customized
employment models require even higher levels of competence and flexibility on the
part of the employment specialists and job coaches (Wehman et al., 2018).
Unfortunately, these hurdles have resulted in segregated work settings (i.e., shel-
tered workshops) and nonwork day programs being used at an ever-increasing
frequency as compared to more effective, integrated, and competitive employment
programs (Wehman et al., 2018).
With any employment training program, successful employment outcome relies
on the effectiveness of the teaching practices being used. Literature reviews have
shown that there are various intervention strategies that are effective when teaching
both vocational skills and “soft skills” to adults with ASD and/or IDD. Vocational
skills are those skills that are necessary to hold a specific job, whereas soft skills are
general social skills that are necessary for any job (organizational skills, conversa-
tion skills, time management, etc.). As with other skills, research has found that
 Autism and Intellectual Developmental Disorder 319

employment-related skills can be effectively learned through behavioral teaching

techniques (Hedley et al., 2017) and that the effectiveness of job coaching can be
enhanced with the use of media and technology (Nicholas et al., 2015). As outlined
by Seaman and Cannella-Malone (2016), use of technology in employment training
has several advantages. First, teaching sessions can be repeated for practice in the
absence of the job coach if audio or video recordings were used for instruction.
Second, the use of audio coaching through earphones allows a job coach to provide
unintrusive and unnoticeable prompts to a learner in natural settings. Third, modern
forms of technology are often cost effective and time efficient, and, fourth, using
technology in employment training allows intervention to be conducted easily in
natural employment settings. Through avoiding the need for simulated settings, this
increases independence and generalization of learned skills.
Technological interventions that have been used successfully to enhance behav-
ioral instruction include video modeling, audio cuing, video prompting, various
mobile apps, and virtual reality (Walsh et al., 2017). In their review of the literature,
Walsh and colleagues concluded that there is enough evidence for the overall use of
technology-aided interventions to be considered probable evidence-based practice for
teaching employment-related skills to adults with ASD; however, there is not yet
enough research evidence to consider any one single intervention (video modeling,
audio cuing, virtual reality, etc.) evidence-based for this purpose and population.
Studies demonstrated the efficacy of technology-aided interventions across a wide
variety of target skills, including specific vocational skills such as clerical skills,
cleaning skills, and clothes folding, as well as soft skills such as time management,
appropriate conversation skills, hygiene behaviors, reasoning skills, and decision-
making (Walsh et al., 2017).

Approaches for Youth

Many of the interventions already discussed are also considered practices for use with
children and adolescents with ASD and/or IDD. In fact, the majority of treatment
research for people with ASD and/or IDD has been conducted with children. In their
review of the literature on evidence-based practice for children with ASD five years of
age and younger, Smith and Iadarola (2015) reviewed the effects of interventions
based on the two predominant theories of autism intervention: applied behavior
analysis (ABA) and developmental social-pragmatic (DSP) models. As discussed
earlier in this chapter, ABA interventions are primarily based on the principles of
operant conditioning, which postulates that behaviors that result in reinforcement will
increase in future circumstances and behaviors that are not reinforced will decrease
(Cooper et al., 2020). ABA interventions can be employed with children in both
educational and therapeutic settings regardless of diagnosis. DSP interventions are
based on the theory that communication, social, and behavioral issues in autistic
320 Frank R. Cicero

children are the result of an impaired ability to engage jointly with other people from
infancy (Smith & Iadarola, 2015). Interventions based on this theoretical model aim to
treat autistic symptoms through initiating semistructured interactions that foster
adult–child joint engagement. Data from their review indicate that both ABA and
DSP interventions are showing some level of evidence, with individual comprehen-
sive ABA (EIBI) and teacher-implemented ABA with DSP interventions being
identified as “well-established” interventions (Smith & Iadarola, 2015). For listings
of specific interventions that have been determined to be evidence-based practice for
autistic youth, the reader is referred to Hume et al. (2021) and Steinbrenner et al.
(2020).
Similar to treatment with children with ASD, interventions for children and
adolescents with IDD typically focus on increasing adaptive and academic skills
and decreasing problem behavior in order to allow for greater independence and
improved overall quality of life. Educational and therapeutic interventions based on
the principles of ABA are most frequently employed. Antecedent-based strategies
(e.g., behavioral momentum, providing choices, using visual or auditory cues, etc.) as
well as consequence-based strategies (e.g., differential reinforcement of appropriate
responding, token economy systems, time out from reinforcement, etc.) have been
found to have empirical support. Treatments should be based on objective assess-
ments of need, generalized across settings, and parent involvement fostered (Scherr
et al., 2018).

Other Variables Influencing Treatment

Assessment and Diagnosis
Both ASD and IDD are diagnosed through diagnostic criteria in the DSM-5-TR
(APA, 2022). Although they are separate diagnoses, they can be codiagnosed by
using the specifier “with accompanying intellectual impairment” under the ASD
category. Standardized screening tools and diagnostic measures have been developed
to assist diagnosticians in conducting diagnostics assessment for ASD. These instru-
ments consist of interviews and direct observation measures that investigate
the presence or absence of core ASD symptoms including social communicative
deficits and restricted and repetitive patterns of behavior (Maye et al., 2017).
Examples of ASD screening and diagnostic instruments include the Autism
Diagnostic Interview-Revised (ADI-R; Lord et al., 1994), Autism Diagnostic
Observation Schedule – Second Edition (ADOS-2; Lord et al., 2012), Childhood
Autism Rating Scale – Second Edition (CARS2; Schopler et al., 2010), and the
Modified Checklist for Autism in Toddlers, Revised with Follow up (M-CHAT-R/
F; Robins & Fein, 2018). For a diagnosis of IDD, deficits in intellectual functions (i.e.,
reasoning, problem solving, abstract thinking, etc.) must be displayed through the
 Autism and Intellectual Developmental Disorder 321

results of a standardized test of intelligence in addition to deficits displayed in one or

more activities of daily life across multiple contexts (APA, 2022).
Once a diagnosis is made, it is important to determine goals to be worked on
within education and therapy. Goals are often developed through a multidisciplinary
team approach, including parents/guardians where appropriate. Professionals on the
team frequently consist of special education teachers, behavior analysts, speech
therapists, residential service providers, nurses, psychologists, occupational therap-
ists, physical therapists, social workers, vocational specialists, and nutritionists.
Psychiatrists, primary care physicians, and medical specialists are often part of the
team as needed.
Once treatment goals have been determined, it is important to conduct several other
assessments to help guide treatment. When treating problem behavior, it is important
to first conduct a functional behavior assessment to determine why the person is
exhibiting the problem behavior. This is done by collecting and analyzing data on the
antecedents (what happens before the behavior) and consequences (what happens
after the behavior) in natural settings. Treatment plans are then tailored to the function
of the problem behavior (Hanley & Slaton, 2019). Preference and reinforcer assess-
ments are other forms of data-based assessment procedures that are used to guide
instruction and treatment. Through these assessments, a person’s likes and dislikes are
determined through systematic presentations of various tangible items and activities.
This is done so that items can be selected to be used as reinforcers (rewards) for
behaviors that are targeted for increase in treatment (Cannella-Malone, 2020). It is
also important to more broadly assess variables such as learning style, treatment
history, environmental supports, and comorbid conditions when designing and imple-
menting treatments for persons with ASD and IDD.
When treating people with ASD and IDD with comorbid mental health conditions,
it is important to first diagnose the specific mental health conditions of concern and
assess the severity levels of the conditions as well as assess progress over the course of
treatment. Unfortunately, many assessment instruments used for treatment with an
adult ASD population have been designed for different purposes than they are being
used for or were validated only on a non-ASD population (Brugha et al., 2015).
Therefore, there is a need for research into the development of mental health assess-
ment instruments geared to this population (Lai et al., 2019).

Comorbidity
At the present time, there are no interventions that have been demonstrated to directly
cure ASD or IDD in affected individuals. This relates to both children and adults. The
majority of evidence-based interventions are designed to treat behavioral issues and
skill deficits resulting from ASD and/or IDD or to treat emotional/behavioral issues
associated with comorbid mental health conditions. It is therefore highly important to
322 Frank R. Cicero

assess the presence of comorbid conditions, behavioral symptoms, and skill deficits
when developing intervention strategies and choosing evidence-based treatments.

Medication
This lack of evidence-based psychotherapy practices with adults with ASD, as well
as with IDD, may account for the high rate of pharmacological interventions used to
treat behavioral issues in these populations (Howlin & Moss, 2012; Sheehan et al.,
2015). It has been found that pharmacological interventions, especially anti-
psychotic medications, are often prescribed to individuals with IDD in place of
psychosocial interventions and in the absence of a diagnosed comorbid mental
health condition (Sheehan et al., 2015). At the present time, there are no medications
that have been found to directly cure ASD or IDD, although some medications (e.g.,
risperidone) have been found effective in reducing specific problem behavior
associated with ASD/IDD such as aggression, self injury, and stereotypy.
Although there are empirically supported pharmacological interventions for the
treatment of mental health conditions in neurotypical adults (e.g., antidepressants,
anti-anxiety medications), more research is needed on the use of pharmacological
interventions for mental health conditions when comorbid with ASD and IDD.
Medications are also frequently used to treat comorbid health conditions in adults
with ASD and IDD (e.g., epilepsy, sleep disorders, gastrointestinal issues, etc.).
Again, however, more research is needed on how pharmacological treatments for
health-related conditions are affected by ASD/IDD.

Conclusion
Adults with ASD and/or IDD have a wide range of skills that can be taught and
behaviors that can be treated with interventions that are showing promising levels of
empirical support in the research literature. As with children with ASD and/or IDD,
many of these interventions are consistent with applied behavior analytic philosophy
and practice. Comorbid mental health concerns, which are frequent in this population,
have been successfully treated with various cognitive-behavioral therapies, including
the relatively recent introduction of mindfulness-based interventions. Unfortunately,
the mental health needs of adults with ASD continue to go unmet due to a lack of
therapist knowledge and expertise on ASD treatment, as well as a lack of knowledge
on how to tailor evidence-based mental health practices to this population (Lipinski
et al., 2022). Long-term outcomes have been improved through the use of compre-
hensive social skills interventions as well as employment training programs.
Although much has been done, there is still much to do. More high-quality research
is required to establish a range of evidence-based comprehensive and focused treat-
ments to improve the quality of life of adults with ASD and/or IDD.
 Autism and Intellectual Developmental Disorder 323

Useful Resources

Books
• Pennington R. C. (2019). Applied behavior analysis for everyone: Principles and practices
explained by applied researchers who use them. AAPC Publishing.
• Cooper, J., Heron, T., & Heward, W. (2020). Applied Behavior Analysis (3rd ed.). Pearson/
Merrill-Prentice-Hall.
• Vargas J. S. (2020). Behavior analysis for effective teaching. Routledge.
• Volkmar, F. R., Rogers, S. J., Paul, R., & Pelphrey, K. A. (2014). Handbook of autism and
pervasive developmental disorders (4th ed.) John Wiley & Sons.

Websites
• American Association on Intellectual and Developmental Disabilities: www.aaidd.org/home
• Association for Behavior Analysis International: www.abainternational.org
• Association for Behavioral and Cognitive Therapies: www.abct.org/
• Association for Professional Behavior Analysts: www.apbahome.net/
• Association for Science in Autism Treatment: https://asatonline.org/
• Autism Speaks: www.autismspeaks.org/
• Behavior Analyst Leadership Council: https://balcllc.org/
• Cambridge Center for Behavioral Studies: https://behavior.org/
• Different Roads: https://difflearn.com/
• Diverse-City Press: https://diverse-city.com/
• Organization for Autism Research: https://researchautism.org/

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 18
Attention-Deficit/Hyperactivity Disorder
Mary V. Solanto

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder

which is usually first apparent in childhood, and, as described in the DSM-5-TR, is
characterized by high levels of inattention, hyperactivity-impulsivity, or both
(American Psychiatric Association, 2022). Once thought to be limited to childhood,
longitudinal outcome studies confirmed that impairing symptoms persist to adulthood
in approximately 60% of childhood cases (Faraone et al., 2015), although more recent
research has identified variable patterns of remission in adulthood (Sibley et al.,
2021). Longitudinal and cross-sectional studies have documented significant impair-
ment in virtually every domain of functioning – academic, occupational, social and
emotional – for adults with ADHD (Barkley et al., 2006), as well as high rates of
comorbid mood, anxiety, and substance abuse disorders (Kessler et al., 2006).

Etiology and Theoretical Underpinnings of Treatment

Although the etiology of ADHD is not fully understood, the primary cause appears to
be genetic, as evidenced by markedly higher rates of concordance for ADHD in
monozygotic versus dizygotic twin pairs (Fitzallen et al., 2023), and identification of
genetic variants that increase risk for ADHD (Agnew-Blais et al., 2021; Demontis
et al., 2019). The neuro-pathophysiology appears to predominantly reside in atten-
tional networks and involves under-activation of the dorsolateral prefrontal cortex,
which is important for executive function, as well as under-activation of subcortical
reward centers important for sustained motivation, as revealed by fMRI studies
(Faraone et al., 2015).
Executive dysfunction is a primary mediator of impairment in ADHD across
functional domains and age groups (Barkley, 2012). Given its substantial correlation
with educational and occupational impairment (Barkley & Fischer, 2011), executive
dysfunction has been the primary target of cognitive-behavioral intervention for adult
ADHD (Young et al., 2016). The goal of CBT for ADHD is to help the individual to
develop behavioral and cognitive strategies to counteract or compensate for deficits in
329
330 Mary V. Solanto

executive self-management in specific contexts, and with respect to specific goals,

problems, and tasks. A positive synergy evolves such that improvements in cognitive
self-instruction generate improvements in behavioral self-management, which in turn
generate more adaptive and self-enhancing cognitions,
Other interventions, such as dialectical behavior therapy (DBT) and mindfulness-
based CBT, have targeted a broad array of other ADHD-related difficulties, including
emotional dysregulation, impulsivity, comorbid internalizing symptoms, and social
function, as well as the core difficulties related to inattention.

Brief Overview of Treatments

Cognitive-Behavioral Therapy
CBT programs that target executive dysfunction in ADHD aim to impart both
behavioral and cognitive skills and strategies to facilitate time management, organ-
ization, and planning. Behavioral aids and corresponding habits include consistent use
of a planner (agenda), systems to organize digital and paper files, a flow-chart to aid
in planning, and removal of distractors (e.g., cell phones) from the workspace.
Cognitive strategies are conveyed and rehearsed in the form of self-instructional
“rules” to guide daily scheduling, prioritizing, and self-activation These programs
typically also incorporate cognitive reframing to target negative automatic beliefs that
generate demoralization, anxiety, and perfectionism (Beck, 1995). Generalization and
maintenance of treatment gains are facilitated through intensive practice within the
sessions and at home via the at-home exercises, as well as through positive reinforce-
ment and support from the therapist and group members.
Following upon successful open trials of CBT to enhance executive function,
Safren et al. (2010) and Solanto et al. (2010) each conducted randomized controlled
trials to test the efficacy of individual and group-based CBT interventions, respect-
ively. These studies employed an active control (“psychological placebo”) for the
nonspecific effects of CBT (relaxation therapy and a support group, respectively). The
sample size for each study was ample at 86 and 88 patients, respectively, who were
randomized to CBT or to the active control group. Results showed that the effect sizes
for the active treatment, as assessed by independent evaluators on structured inter-
views of ADHD symptoms, were moderate at 0.52 and 0.58, respectively (standard-
ized mean difference). Responder rates to CBT were, depending on the outcome
measure, 53–67% (Safren et al., 2010) and 42–53% (Solanto et al., 2010).
The importance of an active control condition in clinical trials of therapies for
ADHD was underscored by the results of a meta-analysis by Young and colleagues
(2016) that reported that the effect size for five studies that lacked an adequate control
for CBT was substantially larger (0.76) than for four studies that included an appro-
priate active control condition (0.43).
 Attention-Deficit/Hyperactivity Disorder 331

On the basis of findings such as those described here, CBT for ADHD has been
designated a well-established intervention by Division 12 (Clinical Psychology) of
the American Psychological Association (https://div12.org/treatment/cognitive-
behavioral-therapy-for-adult-adhd/).

Dialectical Behavior Therapy

There are commonalities between ADHD and borderline personality disorder
(Ditrich et al., 2021) with respect to impulsive behavior, emotional dysregulation
(Beheshti et al., 2020), relationship problems (Wymbs et al., 2021), and low self-
esteem (Harpin et al., 2016). DBT, originally designed to treat borderline personal-
ity disorder, aims to increase emotional and cognitive self-regulation by increasing
awareness of the triggers that lead to reactive states, and by facilitating the applica-
tion of coping skills to avoid undesired reactions. In addition to emotion regulation,
DBT includes skills to increase tolerance of distress, increase mindfulness to
counteract inattention, and improve interpersonal relations.
DBT has been adapted to address the specific needs of adults with ADHD.
Following upon the positive pre- to posttreatment results of an open trial of DBT in
72 participants (Philipsen et al., 2007), Philipsen and colleagues (2015) randomized
419 adults with ADHD to 1 of 4 12-week treatment alternatives: adapted group DBT,
combined with either methylphenidate or placebo, or clinical management (CM)
which included supportive counseling and was also combined with either methyl-
phenidate or placebo. The design thus included active controls in the form of
a placebo for methylphenidate and CM for DBT. Treatment was comprised of
psychoeducation, behavioral analysis, emotional regulation, and mindfulness. The
range of topics, each of which was addressed during one of the 13 weekly 2-hour
sessions, was broad and included the neurobiology of ADHD, disorganization,
emotional regulation, depression, impulse control, stress, addictive behaviors, and
relationships. Results revealed no differences between DBT and CM on the Conners’
Adult ADHD Rating Scales (CAARS) self-report measure of ADHD symptoms,
either at three months or at one-year follow-up. By contrast, participants who received
methylphenidate experienced reduced ADHD symptoms compared to those receiving
placebo, regardless of whether they also received DBT or CM.
A more recent RCT of 121 adults reported that DBT group treatment was more
effective than treatment-as-usual in improving executive function on the Behavior
Rating Inventory of Executive Function – Adult Form (BRIEF-A) (Halmoy et al.,
2022). However, there was no active control for DBT, and change in ADHD symp-
toms was not measured. It may be the case that although DBT is well-conceptualized
as a potential intervention for ADHD, the very multiplicity of topics addressed in the
context of only 13 weekly sessions militates against the efficacy of any one target of
the intervention, necessitating a longer period of intervention.
332 Mary V. Solanto

Box 18.1 Effects on Co-occurring Conditions

An important question for clinicians is whether CBT affects co-occurring conditions,

especially anxiety and depression, which, as described, are common comorbidities in
adults with ADHD (Kessler et al., 2006). The results of a recent meta-analysis (Lopez-
Pinar et al., 2020) have been enlightening in this regard. This meta-analysis included 20
randomized controlled trials of CBT, of which 5 had active controls and 12 had
uncontrolled pre-test/post-test comparisons. CBT significantly improved anxiety and
depression symptoms, as well as quality of life and emotional dysregulation.
Furthermore, these changes were predicted by the reduction in ADHD symptoms,
suggesting a cause–effect relationship. However, treatment was significantly less
effective for depression and anxiety outcomes when compared with active controls,
suggesting that remediation of internalizing symptoms is a nonspecific result of therapy.

Credible Components of Treatments

Tolin and colleagues (2015) observed that while recent intervention research has
adduced empirical clinical support for the efficacy of treatment “packages” with
manualized protocols, there has been little investigation of the active principles of
change that underlie these treatments, and little testing of the efficacy of the individual
components (i.e., dismantling studies). Although the efficacy of the individual com-
ponents of CBT for ADHD have not been determined, it is possible to delineate these
components and to generate hypotheses regarding their mechanisms of action.
Illustrations of specific strategies are taken from the published CBT treatment proto-
col for therapists, developed by Solanto (2011).

The Centrality of Learning Theory

Like other cognitive and behavioral interventions, CBT is grounded in learning
theory, particularly operant conditioning: namely, that behaviors that are rewarded/
reinforced will increase in frequency (Beck, 1995). In cognitive-behavioral interven-
tions, that reinforcement comes initially from the therapist who describes to the
patient the rewards which will be available contingent upon shifting to a more
effective behavior. As the patients begin to test out an adaptive behavior, and they
experience the positive results, the new behaviors become self-reinforcing and ultim-
ately autonomous. Group therapy adds therapeutic elements – specifically, the oppor-
tunity for positive modeling and vicarious reinforcement of successful strategies.
Support and encouragement from other group members provide additional opportun-
ities for positive reinforcement of adaptive behavior changes. In some programs
(Solanto, 2011), self-reinforcement (i.e., planned access to discrete preferred
 Attention-Deficit/Hyperactivity Disorder 333

activities) upon completion of aversive, boring, or unpleasant tasks is explicitly

guided and encouraged via a home exercise as an early strategy in the program.

Time Estimation
Multiple studies have shown that adults with ADHD have deficits in time perception,
including time estimation and time awareness, which may represent a fundamental
substrate of dysfunction in ADHD, and may be mediated by anomalies in the
cerebellum (Barkley et al., 2001). Difficulty estimating how long things take, and
poor awareness of the passage of time, will obviously impair planning and will inhibit
efforts to adjust one’s pace according to situational demands. An exercise in the CBT
group protocol is intended to increase time awareness and improve time estimation by
having participants estimate how long they believe certain routine tasks and activities
at home or at the office require (e.g., getting ready to leave the house in the morning,
cleaning up after dinner, producing a given type of report at work) and then actually
timing those activities to assess the accuracy of estimation. It is conjectured that
repeated exercises of this type will improve time perception, but there is virtually no
research literature on the effectiveness of this or any intervention to improve time
perception in adults with ADHD.

Temporal Discounting
A major problem for most people with ADHD is the tendency to avoid or delay the
initiation or completion of tasks that are perceived as effortful, difficult, and/or
lacking in stimulation or gratification. So, for example, a college student with
ADHD may succumb to the desire to go out partying with friends on a given night
rather than stay home to study for an upcoming test. This tendency, which may be
conceptualized as the preference for smaller sooner over larger delayed rewards, is
otherwise known as “temporal discounting,” and has been demonstrated in both
children and adults with ADHD (Jackson & MacKillop, 2016) when they make
choices between smaller and larger rewards at different time delays on computerized
laboratory measures. Repeated over thousands of iterations across the lifespan and
exhibited in the workplace as well as in school, this tendency may account for the
lessened success of many individuals with ADHD both academically and occupation-
ally, as documented in the longitudinal outcome studies. A strategy to counteract this
tendency is to increase the salience of the distant reward in order to motivate the
individual to pursue that larger/more important reward (e.g., a better grade on the test
or in the course) in preference to immediately available rewards.
In the group CBT program (Solanto, 2011), this goal is pursued by having the
participant actively “fast-forward” and envision, as vividly as possible, the tangible
and intangible rewards that will accompany the distant goal. In the laboratory, an
334 Mary V. Solanto

analogous process, termed “Episodic Future Thinking” (EFT), in which the individual
is instructed to imagine the rewards associated with achievement of the larger delayed
reward, has been shown to reduce temporal discounting (Scholten et al., 2019) and
would appear to be a good candidate for evaluation of “real-world” clinical effective-
ness in ADHD. Early in the CBT program this approach is applied to the goal of
helping participants cease engrossing late-night activities (the “immediate” rein-
forcers) and get to bed early enough to get adequate sleep, thereby avoiding fatigue,
grogginess, and lateness to school or work the next day, which are chronic difficulties
for many with ADHD.

Prioritizing and Planning

Awareness of and attention to important future events is also facilitated by the use of
several aids incorporated into the program. These include plotting tasks and activities
on a 2 × 2 (i.e., urgency × importance) matrix, in which “urgent” items are those which
are time-sensitive, with no implications for their importance. Regular use of the
matrix, included in the session on prioritization, is intended to help the individual
weigh the benefits of future “important” gains (e.g., a possible promotion at the office
for working overtime on a project) against the appeal of more immediate (“urgent”)
gratifications (e.g., watching TV all evening instead).
Use of a flow-chart is incorporated into the module on planning as a visual aid to
planning a complex task or project. Completion of the chart facilitates identification of
all the steps that must be executed to complete the project, their sequence, and the
anticipated time which must be allocated for each in order to complete the entire
project by a given deadline.

Self-Instruction via “Mantras”

Throughout treatment, patients are helped to develop self-instructive cognitions
which cue the application of adaptive strategies. Some of these are crystallized as
aphorisms or “mantras” which are repeated strategically throughout treatment in the
hope that they will be internalized as automatic guides to behavior and thereby serve
to facilitate generalization and maintenance of adaptive strategies. One of these is “If
it’s not in the planner, it doesn’t exist,” meaning that unless appointments and
(especially) tasks are entered into the planner, they are unlikely to be accomplished.
Another mantra is, “If I am having trouble getting started (i.e., procrastinating), then
the first step is too big,” which is the cue to chunk a difficult or aversive task/activity
into more manageable parts. This mantra also takes advantage of “if–then” thinking
which cues both the problem situation and an appropriate solution. Research has
demonstrated that administration of methylphenidate and the use of if–then planning
equivalently improved inhibition of an unwanted response on a “Go/NoGo” task, and
 Attention-Deficit/Hyperactivity Disorder 335

increased the P300 attending response on EEG (Paul-Jordanov et al., 2010). The
strategy of chunking itself, and the verbally encoded aids to facilitate it, represent
good targets for future dismantling research.

Cognitive Reframing
As also included in the programs developed by Ramsay and Rostain (2014), the
programs by Safren et al. (2005) and Solanto (2011) included sessions on
identifying and debunking or reframing automatic negative thoughts such as
those reflecting “overgeneralization,” “disqualifying the positive,” “all-or-none
thinking,” “personalization,” and “catastrophizing.” Such thoughts generate anx-
iety and depression, and serve to inhibit positive changes in behavior. It would
be of interest to test the incremental efficacy of this approach when included
with the behavioral strategies described earlier.

Mindfulness
Mindfulness, which is described as purposeful, nonjudgmental attention to the present
moment, is developed through meditation and other practices. In the teaching of
mindfulness, an individual is guided to become aware of incoming thoughts, feelings,
and sensations, to observe and accept them without judgment, and then to disengage
from them (Kabat-Zinn, 1996). Originally inspired by teachings from the East, training
in mindfulness has been applied to relieve patient stress, anxiety, pain, and other
problems. Mindfulness-based cognitive therapy (MBCT) combines the clinical appli-
cation of mindfulness training with elements of cognitive-behavioral intervention, such
as cognitive reframing, and showed early promise as an intervention to improve focus
for people with ADHD (Househam & Solanto, 2016). Zylowska and colleagues (2008)
reported the results of an open trial of an 8-week program of mindfulness meditation
with 24 adults and 8 adolescents, which showed improvement on self-report ratings of
ADHD symptoms, depression, and anxiety, as well as increased performance on
cognitive tests of attention and impulse control. The results of more recent research,
however, have been mixed. Positive findings have been reported in comparison with
treatment-as-usual (Janssen et al., 2019; Mitchell et al., 2017) but not when compared
with an active control condition (Bachmann et al., 2018; Hoxhaj et al., 2018).

Approaches for Youth

The most effective form of psychosocial therapy for children with ADHD is behavior
therapy, which focuses upon the child’s overt behaviors rather than their thoughts/
cognitions. Behavior therapy is grounded in learning theory, principally operant
conditioning. The well-established types of behavior therapy for youth with
336 Mary V. Solanto

ADHD include behavioral classroom management, behavior parent training, and

behavioral peer interventions (Evans et al., 2014). Organizational training is also
well established (Abikoff et al., 2013). These approaches involve the systematic
manipulation, primarily by parents and teachers, of the antecedents and conse-
quences of targeted behaviors, with positive reinforcement for desired behaviors
and time-out, loss of privileges, or penalties for negative behaviors.
Over the 50 years since its introduction, an extensive literature has documented the
effectiveness of behavior therapy (Fabiano et al., 2009). The landmark NIMH-
sponsored MTA study (Multi-modal Treatment of ADHD) found that although
behavior therapy was less effective than stimulant medication (MTA Cooperative
Group, 1999), it added to the benefit of medication for some outcomes (Swanson
et al., 2001), notably parent–child conflict, academic difficulties, and anxiety. More
recently, Sonuga-Barke and colleagues (2013) conducted a meta-analysis of 14
randomized controlled trials of behavior therapy and reported that inclusion of studies
involving both “probably blinded” and “unblinded” raters yielded a significant effect
size of 0.40–0.64 (moderate) for core symptoms of ADHD, whereas limiting the
analysis to those trials (k=7) which were “probably blinded” reduced the effect of the
treatment to insignificance. However, a follow-up meta-analysis of the same set of
studies (Daley et al., 2014) found that effects were significant for other outcomes
(parenting quality, conduct problems, academic performance, and social skills) in
studies involving probably blinded and unblinded raters, whether considered separ-
ately or together.

Other Variables Influencing Treatment

Assessment and Diagnosis
Moderating effects of clinical variables on response to psychotherapy for adult
ADHD have generally not been investigated. Solanto et al. (2010) found no moderat-
ing effect on response to treatment on the basis of ADHD subtype or concurrent
medication for ADHD. In that study, however, severity of self-rated (but not clinician-
rated) inattentive ADHD symptoms at baseline predicted a better response to treat-
ment on self-reported (but not clinician-rated) ADHD symptoms. That study also
reported that within the CBT group, the number of completed Home Exercises was
a significant positive predictor of reduction in posttreatment clinician-rated inatten-
tive symptoms.

Comorbidity
No studies have reported that presence of comorbid anxiety or depression was
a predictor of response to CBT. Rather, as referenced earlier, there is evidence
indicating that CBT has a salutary effect on comorbid anxiety or depression.
 Attention-Deficit/Hyperactivity Disorder 337

Demographics
Patient demographic variables have been insufficiently examined as potential
moderators of treatment outcome. Solanto et al. (2010) found no effect of
gender, race, education, household income, marital status, employment status,
or IQ on outcome of treatment. Age had no moderating effect when examined as
a continuous variable. However, in a subsequent study (Solanto et al., 2018) in
which the same sample was dichotomized into subgroups of individuals 50 years
of age or older and those less than 50, it was found that the older group
responded as well to CBT as did the younger patients. Interestingly, they
responded to support as well as they did to CBT, demonstrating a better
response to support than did the younger group of patients.

Medication
Consistent with the conceptualization of ADHD as a brain-based condition,
stimulant medication has been shown to be highly effective and is considered
the drug class of choice for treatment of the core attentional and impulsive
symptoms of ADHD. However, response rates in adults are lower than they are
in children (Cortese, 2020), and it is apparent that additional, nonpharmacolo-
gical interventions are needed to address the executive dysfunction, emotional
dysregulation, impulsivity, relationship problems, comorbid anxiety and depres-
sion, and low self-esteem which persist among adults with ADHD, even after
stimulant medication is optimally titrated.
An important issue for clinicians, therefore, is whether CBT augments the benefit
of medication to treat ADHD, and, conversely, whether medication augments the
benefit of CBT. In the absence of a fully crossed 2 × 2 design, in which adults with
ADHD are randomly assigned to receive either CBT or an active control therapy,
combined with either medication or placebo, we must rely on studies that have
conducted these comparisons separately.
Does CBT add to the benefit of medication? Five studies have assessed the benefits
of adding CBT to medication, with four studies reporting positive results (Emilsson
et al., 2011; Pan et al., 2022; Wettstein et al., 2021; Young et al., 2015) and one study
reporting negative results (Corbisiero et al., 2018). None of these five studies included
an active control for CBT, however, so these results must be viewed as tentative, and
more research is needed.
Medication clearly added to the benefit of CBT in one controlled, adequately
powered study (Cherkasova et al., 2020) in which adults with ADHD were
randomized to receive CBT + stimulant medication (n=42) or CBT + placebo
(n=46). Medication was individually titrated and optimized. Results were super-
ior for the CBT + medication group with respect to ADHD symptoms, organ-
izational skills, and self-esteem. An earlier study (Weiss et al., 2012) had
338 Mary V. Solanto

reported that medication did not add to the benefits of CBT – that is, the effects
of CBT alone and CBT + medication were not significantly different. Yet
another result, reported by Pan et al. (2019) was that CBT + medication
(n=57) was not superior to CBT alone (n=67) in improving ADHD symptoms,
emotional symptoms, or social functional outcomes, but was more effective with
respect to executive function. However, this study was not a randomized trial.
Patients in the CBT + medication group had been titrated and stabilized on
medication in the clinic before the study began, and were then asked to partici-
pate in a study of CBT. Thus, poor or nonresponders to medication may have
self-selected to receive additional treatment with CBT. In the study by
Cherkasova and colleagues (2020), by contrast, patients were randomly assigned
to treatment conditions and titration was initiated within the study proper.
Insufficiently explored is whether CBT and medication each target different
clinical outcomes, which might be predicted given their differing mechanisms
of action.

Conclusion
Although stimulant medication is broadly effective in reducing core symptoms
of ADHD, other therapies are needed to address commonly co-occurring condi-
tions in adults, including executive dysfunction, emotional dysregulation, comor-
bid internalizing disorders, and social difficulties. CBT primarily targets
executive dysfunction, and appears to fully meet criteria as a well-established
intervention by the APA Division 12. By contrast, a large-scale well-designed
study of DBT (Philipsen et al., 2015) which addressed a broad array of accom-
panying conditions, including emotional dysregulation, impulse control, stress,
addictive behaviors, and social relationships, performed no better than “clinical
management,” suggesting that over-inclusion of treatment targets militates
against the successful treatment of any one dysfunction. Positive results have
been reported for mindfulness when compared to treatment-as-usual, but not
when compared to an active control condition.
CBT for ADHD has yet to be fully evaluated against the criteria delineated
by Tolin et al. (2015) for an empirically supported treatment (EST). Treatment
and patient variables yet to be fully addressed include: the long-term mainten-
ance of treatment gains, effectiveness in “real-world” contexts with demograph-
ically and clinically diverse samples, and dismantling to identify the efficacy
and mechanisms of action of individual treatment components. All in all,
however, with continued research and refinement, CBT has the potential to
substantially improve the functioning of adults with ADHD in multiple
domains.
 Attention-Deficit/Hyperactivity Disorder 339

Useful Resources

Books For Therapists

• Ramsay, J. R., & Rostain, A. L. (Eds.). (2014). Cognitive-Behavioral Therapy for Adult
ADHD: An Integrative Psychosocial and Medical Approach (2nd ed.). Routledge.
• Safren, S. A., Sprich, S., Perlman, C., & Otto, M. (2005). Mastering Your Adult ADHD:
A Cognitive-Behavioral Treatment Program (Therapist Workbook). Oxford University Press.
• Solanto, M. V. (2011). Cognitive-Behavioral Therapy for Adult ADHD: Targeting
Executive Dysfunction. Guilford Press.

For Patients
• Safren, S. A., Sprich, S., Perlman, C., & Otto, M. (2005). Mastering Your Adult ADHD:
A Cognitive-Behavioral Treatment Program (Client Workbook). Oxford University Press.
• Surman, C., Bilkley, T., & Weintraub, K. (2014). Fast Minds: How to Thrive If You Have
ADHD (Or Think You Might). Penguin Publishing Group.
• Tuckman, A. (2009). More Attention, Less Deficit: Success Strategies for Adults with
ADHD. Specialty Press/ADD Warehouse.
• Zylowska, L. (2012). The Mindfulness Prescription for Adult ADHD: An 8-Step Program
for Strengthening Attention, Managing Emotions, and Achieving Your Goals: Shambhala
Press.

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 19
Tic Disorders
Kirsten Bootes, Emily Braley, and Michael B. Himle

Tics are sudden, rapid, recurrent, nonrhythmic movements and/or vocalizations (i.e.,
motor and vocal tics; APA, 2022) that fall along a continuum of complexity ranging
from simple to complex. Simple tics are brief, purposeless movements involving
a small number of discrete muscle groups (e.g., blinking, head-jerking) or the
production of brief, meaningless sounds (e.g., sniffing, snorting, chirping).
Complex tics have a more purposeful and sustained appearance and involve orches-
trated patterns of movement or elaborate vocalizations that mimic goal-directed
actions or speech (e.g., patterned touching and tapping, shouting of words or phrases,
echo- and coprophenomena). Diagnostically, there are three primary, hierarchically
arranged, tic disorder (TD) diagnoses that are differentiated by the types of tics
present (i.e., motor, vocal, or both) and the duration of symptoms since initial onset
(APA, 2022). Tourette’s disorder involves multiple motor and at least one vocal tic
that have been present for at least one year. Persistent motor or vocal tic disorder
involves single or multiple motor or vocal tics (but not both) that have been present for
at least one year. Finally, provisional tic disorder involves single or multiple motor
and/or vocal tics that have been present for less than one year. In all three cases,
diagnosis requires that tics begin prior to 18 years of age and that they are not
attributable to the physiological effects of a substance or another medical condition.
Subjectively, most individuals with TDs report that their tics are preceded by unpleas-
ant somatic sensations, referred to as premonitory urges, that are typically described
as an uncomfortable feeling localized to the area of the tic or a vague sense that
something is “just not right” in the body. Most individuals report that their premoni-
tory urges worsen when they attempt to suppress their tics and that they are temporar-
ily alleviated when the tic is performed (Kwak et al., 2003).
The clinical course of TDs is highly variable; however, tics typically first emerge in
early childhood, take a notable waxing and waning course, spontaneously change in
appearance over time, and reach peak severity in early adolescence. In approximately
50–75% of cases, tics significantly improve by early adulthood (Bloch & Leckman,
2009). For those for whom tics persist into adulthood, they can be a source of
344
 Tic Disorders 345

significant distress, discrimination, impairment, and reduced quality of life (Conelea

et al., 2013). Adult-onset tics are relatively rare, and in most cases are secondary to
substance exposure, an identifiable medical condition, or adult re-emergence of
childhood tics (Jankovic et al., 2010). Epidemiological studies have shown that TDs
affect 1–3% of school-aged children (Hornsey et al., 2001; Robertson, 2008); how-
ever, precise prevalence estimates in adults have been difficult to determine, due in
part to the removal of the distress and impairment criteria from recent editions of the
DSM and uncertainty regarding how longitudinal course should be considered when
conferring a diagnosis.

Etiology and Theoretical Underpinnings of Treatment

Current empirically supported treatments for tics are based on a biobehavioral model
that incorporates what is known about the underlying pathophysiology of tics with
principles of learning theory to explain how internal and external contextual stimuli
and tic-contingent consequences exacerbate and maintain tics (Woods et al., 2008).
While the exact etiology of TDs remains unclear, there is converging evidence that
tics are the result of structural and functional abnormalities within cortico-striatal-
thalamic-cortical (CSTC) circuitry that subserve a host of important integrative motor
and sensorimotor functions, including the selection and execution of goal-directed
and habitual actions, inhibition, habit formation, and reward processing, among others
(Ganos et al., 2013). Tic disorders are also highly heritable. Recent genome-wide
association studies suggest the inheritance patterns responsible for TDs are complex
and polygenetic, but the specific genes and risk factors involved remain unknown
(Lin et al., 2022).
The behavioral component of the biobehavioral model centers around two primary
tenets. First, studies have shown that tics can be influenced by internal and external
contextual factors (i.e., antecedents; Conelea & Woods, 2008). For example, most
individuals report that their tics fluctuate in specific settings, when engaged in certain
activities, and in response to their emotional state (Himle et al., 2014). Likewise,
studies have shown that tics can be exacerbated or attenuated by tic-contingent
consequences such as attention and/or avoidance of nonpreferred tasks (Himle
et al., 2014). Importantly, the impact of specific antecedents and consequences on
tics is highly idiosyncratic and believed to be based on an individualized learning
history. The second primary tenet of the behavioral model is that tics function to
temporarily remove or reduce aversive premonitory urges, and thus tics are hypothe-
sized to be strengthened through automatic negative reinforcement (Evers & van de
Wetering, 1994). Furthermore, because tics are executed regularly across contexts
and are immediately reinforced by a reduction in the premonitory urge, they become
overlearned (i.e., habitual) behaviors that occur outside of immediate awareness
(Singer, 2016). Based on these two tenets, the primary goals of behavioral approaches
346 Kirsten Bootes, Emily Braley, and Michael B. Himle

to tic management are to systematically identify and modify tic-exacerbating ante-

cedents and consequences, to increase the individual’s awareness of tics and associ-
ated urges, and to teach patients to interrupt or suppress tics, especially when in the
presence of tic-eliciting stimuli. Doing so is thought to disrupt the reinforcement
processes maintaining tics and facilitate habituation to premonitory urges (Himle
et al., 2006; Verdellen et al., 2008).

Brief Overview of Treatments

Habit Reversal Training
Habit reversal training (HRT) is a collection of behavior modification techniques that
was originally developed to treat a broad range of problematic repetitive behaviors,
including motor and vocal tics (Azrin & Nunn, 1973). The rationale for HRT is based
on the assumptions that tics occur outside of the patient’s immediate awareness and
are reinforced through both automatic and socially mediated reinforcement contin-
gencies. The goal of HRT is to extinguish the reinforcement contingencies maintain-
ing tics by increasing the patient’s awareness of when a tic is about to occur (or has
occurred) and then teaching and reinforcing tic suppression strategies to interrupt or
prevent tic occurrence. The original HRT treatment package consisted of a set of
sequentially delivered therapeutic techniques that included self-monitoring, aware-
ness training, competing response training, social support, and several additional
therapeutic procedures to enhance motivation and generalization (Azrin & Nunn,
1973). Subsequent dismantling studies have shown that a simplified version of HRT
that involves only awareness training, competing response training, and social support
may be sufficient (Miltenberger & Fuqua, 1985). Each component of HRT is applied
sequentially to each tic in the patient’s repertoire, typically with one tic targeted per
week, and the patient is assigned to practice using competing responses between
sessions in settings and contexts in which the tic is likely to occur.

Comprehensive Behavioral Intervention for Tics

Comprehensive Behavioral Intervention for Tics (CBIT) is a multicomponent treat-
ment package that combines several behavioral tic management strategies into
a single comprehensive treatment package. The primary components of CBIT include
psychoeducation, simplified HRT (i.e., awareness training, competing response train-
ing, and social support), a function-based assessment and intervention (FBAI) proto-
col designed to systematically identify and modify or eliminate tic-exacerbating
antecedents and consequences, relaxation training, and motivational techniques to
increase treatment compliance and the use of tic management strategies outside of
sessions (Woods et al., 2008). The CBIT treatment protocol is designed to be flexibly
 Tic Disorders 347

administered across eight weekly sessions, delivered over the course of 10–12 weeks,
with a different tic targeted in treatment each week (Woods et al., 2008; Piacentini
et al., 2010; Wilhelm et al., 2012).

Exposure and Response Prevention

Like HRT, the rationale for applying exposure and response prevention (ERP) to
treat tics assumes that tics are strengthened through automatic negative reinforce-
ment (i.e., function to reduce aversive premonitory urges). As such, the ERP
approach hypothesizes that if a patient suppresses their tics for a prolonged period
of time (i.e., response prevention) they will be repeatedly “exposed” to their
premonitory sensations, which will result in habituation to the urge and a decrease
in the overall frequency and severity of tics (Verdellen et al., 2004). Within the ERP
protocol, patients are encouraged to suppress all tics for increasingly longer dur-
ations of time while also periodically reporting the strength of their premonitory
urges in order to reinforce the notion that premonitory urges will eventually
decrease if tics are suppressed. Treatment typically consists of 12 2-hour sessions,
and patients are encouraged to practice tic suppression while engaged in tic-
exacerbating activities (Hoogduin et al., 1997).

Overall Level of Research Support

The Society of Clinical Psychology does not identify any empirically supported
treatments for TDs at this time. Several small-N and uncontrolled group design
studies and small randomized controlled trials provided early support for the efficacy
of HRT; however, these studies had methodological shortcomings that limited confi-
dence in their findings (see Himle et al., 2006 for a review). More recently, the
efficacy of behavior therapy for TDs was demonstrated in two large multisite
randomized controlled trials (parallel adult and child trials) comparing CBIT to
psychoeducation plus supportive therapy (PST). In the child trial (n=126 children
with TD), 53% of children who received CBIT were classified as treatment
responders, compared to 19% of children who received PST (Piacentini et al.,
2010). CBIT also resulted in a significantly greater decrease in overall tic severity
compared to PST, and treatment gains were durable, with 87% of CBIT responders
maintaining their gains 6-months posttreatment. In the adult trial (122 patients, ages
16–69 years), 38% of patients who received CBIT were rated as treatment responders
versus 6% of those who received PST, and 80% of CBIT responders maintained their
gains at 6-month follow-up (Wilhelm et al., 2012). Those who received CBIT also
showed a significantly greater reduction in overall tic severity. The efficacy of HRT/
CBIT is further supported by several meta-analytic studies showing medium-to-large
treatment effect sizes across randomized control trials (McGuire et al., 2014; Wile &
348 Kirsten Bootes, Emily Braley, and Michael B. Himle

Pringsheim, 2013; Yu et al., 2020). Based on the current state of evidence supporting
CBIT, it is now recommended within several practice guidelines as a first-line
intervention for treating tics in both children and adults whose tics are bothersome
(Pringsheim et al., 2019). ERP has been less extensively studied but has been shown
to be effective in several small studies and three randomized controlled trials (Andren
et al., 2019; Hollis et al., 2021; Hoogduin et al., 1997; Verdellen et al., 2004;
Wetterneck & Woods, 2006; Woods et al., 2000). A recent meta-analysis found
a small-to-medium effect size for ERP for TDs; however, this study included only
three studies in their analysis, two of which examined a therapist-supported online
delivery format (Yan et al., 2022).

Credible Components of Treatments

Although the treatment packages described herein differ with respect to the
specific therapeutic procedures they employ, each is based on a similar biobe-
havioral model and shares several specific, theoretically driven treatment com-
ponents designed to alter internal and external learning processes hypothesized
to strengthen and maintain tics. The primary credible treatment components
shared across HRT, CBIT, and ERP are described in the following sections.

Increasing Awareness of Tics

Most individuals with TDs are largely unaware of their tics and associated urges on
a moment-to-moment basis (Müller-Vahl et al., 2014; Singer, 2016). Because aware-
ness of tics and associated premonitory urges is thought to facilitate and enhance tic
suppression, awareness training strategies are a central component of behavioral
interventions for TDs. Within the HRT protocol, awareness training is an explicit
multistep process. It begins with response description, which involves asking the
patient to describe the progression of body parts, movements, sensations, and pre-
monitory urges involved in the target tic. The second step of awareness training
involves teaching the patient to recognize and acknowledge discrete occurrences of
the target tic as early in the tic chain as possible, ideally before it occurs, by detecting
the associated premonitory urge. In-session awareness training procedures are sup-
plemented with between-session practice and self-monitoring. In contrast to HRT, the
ERP protocol does not contain specific instructions or activities for increasing aware-
ness prior to teaching tic suppression. Rather, strategies to increase awareness are
embedded into the ERP suppression protocol.
Although awareness training is considered a theoretically important component
of behavioral treatment packages for TDs (especially for HRT), additional research
is needed to better understand whether awareness training is an essential component
of the HRT/CBIT treatment package, as well as the level of awareness that is
 Tic Disorders 349

necessary and/or sufficient for optimal treatment outcomes. Furthermore, whether

embedded (i.e., ERP) or explicit (i.e., HRT) procedures are differentially effective
for increasing awareness of tics and associated premonitory urges is unknown.
Finally, although awareness training alone has been shown to decrease tics in
a few uncontrolled case studies (Wiskow & Klatt, 2013; Wright & Miltenberger,
1987), there have been no systematic investigations examining awareness training
as a stand-alone treatment for TDs.

Tic Suppression
Therapeutic strategies aimed at teaching and/or encouraging patients to suppress their
tics are also a core component of treatment. Tic suppression is believed to disrupt the
negative reinforcement cycle, facilitate habituation to the premonitory urge, and
weaken urge-tic associations (Himle et al., 2006). Within HRT (and CBIT), tic
suppression is accomplished through competing response training, which involves
teaching the patient to engage in a behavior that is physically incompatible with the tic
(i.e., a competing response) whenever a tic occurs or is about to occur. As a general
rule, an effective competing response is a behavior that: (1) is physically incompatible
with the tic or interferes with performance of the tic to the greatest extent possible, (2)
a response that can be maintained without difficulty for several minutes, (3) is less
conspicuous than the tic itself, and (4) does not interfere with routine activities (e.g.,
walking, driving, talking). The patient is instructed to engage in the selected compet-
ing response whenever they recognize that a tic has occurred or begun, or, ideally,
whenever they detect a premonitory urge. The patient is also instructed to maintain the
competing response for at least one minute or until the urge to tic subsides, whichever
is longer. Whenever the patient exhibits a tic, the therapist prompts them to use the
competing response, and unprompted use of the competing response is reinforced
with praise. The patient is then instructed to practice using the competing response
regularly between sessions, particularly when in high-risk settings or engaged in tic-
exacerbating activities. In one small component analysis study, competing response
training was found to be necessary (above and beyond awareness training, self-
monitoring, and social support) for reducing motor tics in two of four children
(Woods et al., 1996); however, additional dismantling studies with larger sample
sizes are needed to better understand its incremental benefit when delivered as part of
the HRT/CBIT treatment package.
ERP also emphasizes tic suppression as a primary component of treatment; how-
ever, the patient is not typically taught a specific strategy for suppressing their tics.
Rather, patients are asked to suppress their tics for as long as possible and are
challenged to do so for increasing durations of time (Verdellen et al., 2011a;
Verdellen et al., 2011b). In addition, whereas HRT focuses on treating one tic at
a time, in ERP patients are instructed to suppress all of their tics simultaneously.
350 Kirsten Bootes, Emily Braley, and Michael B. Himle

Finally, unlike in HRT, in which patients are encouraged to practice inhibiting their
tics while multitasking (i.e., distracted), in ERP patients are explicitly encouraged to
focus on and tolerate premonitory urges until habituation occurs. This later element of
ERP is presumably based on the assumption that distraction will interfere with
habituation and/or expectancy violation (i.e., providing corrective information to
counter the belief that urges will not decrease); however, these assumptions have
not been empirically tested.

Social Support
Social support involves recruiting a supportive person, such as a spouse, partner,
friend, or family member, to assist the patient in practicing therapeutic techniques
between sessions. The social support person’s role primarily involves assisting with
between-session awareness training exercises (HRT/CBIT), prompting and reinfor-
cing the use of competing responses (HRT/CBIT), assisting with tic suppression
practice (ERP), and providing general encouragement and support. Although
a component analysis study of HRT applied to treat adults with body-focused
repetitive behaviors suggested that the social support component of HRT did not
add incremental benefit (Flessner et al., 2005), there is evidence to support the use of
social support when applying HRT/CBIT to treat tics. For example, Woods et al.
(1996) sequentially applied the core components of HRT for four children with
motor tics and found that social support improved outcomes in three of the four
participants. In addition, follow-up analysis of the child and adult CBIT trials found
that compliance with between-session homework predicted better treatment
response (Essoe et al., 2021). More research is needed, however, to better under-
stand the relative importance of the specific activities assigned to the social support
person (e.g., assisting with awareness activities, reinforcing use of the competing
response, etc.) and how to tailor social support to individual patients to maximize
therapeutic benefit.

Identifying and Modifying Tic-Exacerbating Antecedents and Consequences

A primary component of treatment for tics involves identifying and modifying or
eliminating antecedents and tic-contingent consequences associated with tic
exacerbations. Within CBIT, this process is referred to as function-based assess-
ment and intervention (FBAI; Woods et al., 2008). The FBAI process begins with
a systematic functional assessment, in which patients are queried about specific
antecedent stimuli (i.e., tic triggers) and consequences (i.e., tic reactions) that have
been shown in the research literature to be commonly associated with tic worsen-
ing (Himle et al., 2014). Patients are also assigned to regularly self-monitor their
tics between sessions and to record both antecedents and consequences associated
 Tic Disorders 351

with situational tic worsening. Based on the information gleaned from the func-
tional assessment and self-monitoring, a collection of individualized function-
based interventions is collaboratively created and implemented with the goal of
eliminating or reducing tic-exacerbating contextual factors (i.e., creating a “tic-
neutral” environment; Walkup et al., 2012). Function-based environmental modi-
fication strategies have been shown to be effective for reducing tics in several
small studies (Conelea & Woods, 2008; Roane et al., 2002; Wagaman et al., 1995;
Watson & Sterling, 1998); however, additional research is needed to validate the
function-based assessment procedures utilized in CBIT and to determine the
extent to which FBAI procedures contribute to therapeutic outcomes (and for
whom).
When tic-exacerbating antecedents and consequences cannot be feasibly elim-
inated, the patient is assigned to practice in vivo tic suppression strategies within
that context or to engage in in-session simulations (Woods et al., 2008;
Verdellen et al., 2011a). Although tic-exacerbating functional variables are
unique to each patient, most individuals report that stress, anxiety, and muscle
tension increase tics (Caurin et al., 2014). As such, within CBIT all patients are
taught relaxation techniques such as deep breathing and progressive muscle
relaxation (Woods et al., 2008). Although research has shown that relaxation
training can situationally reduce tics (Tilling & Cavanna, 2020), results of
a comparison study show that relaxation training is less effective than self-
monitoring and HRT (32% tic reduction compared to 44% and 55%, respect-
ively; Peterson & Azrin, 1992), and therefore there is insufficient support to
recommend relaxation techniques as a stand-alone monotherapy for TDs (Tilling
& Cavanna, 2020). Furthermore, acute stress has been shown to undermine tic
suppression (Conelea et al., 2011), suggesting that relaxation techniques might
enhance suppression-based therapeutic techniques, though further research is
needed to test that hypothesis.

Motivational Techniques
Studies have shown that between-session practice of therapeutic activities, espe-
cially later in the course of treatment, increases the likelihood that patients will
ultimately benefit (Essoe et al., 2021). Strategies to increase motivation are thus
interspersed throughout treatment protocols – for example, through frequent
encouragement and reinforcement for treatment engagement, self-managed reward
programs (e.g., token economies), and regularly tracking and reviewing treatment
progress (Woods et al., 2008). Although follow-up analysis of the child and adult
CBIT trials found that compliance with between-session homework predicted better
treatment response (Essoe et al., 2021), the most effective strategies for motivating
treatment engagement and compliance remain unknown.
352 Kirsten Bootes, Emily Braley, and Michael B. Himle

Generalization, Mastery, and Maintenance Strategies

Embedded within treatments for tics are strategies that support the generalization
and mastery of skills taught in treatment. For example, patients are encouraged to
self-monitor their tics outside of session and to practice awareness and tic
suppression procedures across a wide range of contexts, especially those associ-
ated with tic worsening. In addition, even treatment responders are likely to have
new tics emerge (Peterson et al., 2016) and/or to encounter novel situations that
exacerbate residual tics (e.g., stressful life events). Thus, relapse prevention
strategies are included as part of treatment. For example, in CBIT, the final two
sessions are dedicated to topics such as monitoring for the onset of new tics and
the re-emergence of successfully treated tics, continued monitoring for tic-
exacerbating antecedents and consequences, and simulated practice applying
CBIT skills to novel tics to ensure that the patient can apply the primary
components of treatment to new tics (Woods et al., 2008). Patients are also
encouraged to periodically attend booster sessions, as needed, following the
acute phase of treatment in order to maintain treatment gains (Woods et al.,
2008). Although the effectiveness of booster sessions within CBIT has not been
specifically examined, such sessions have been shown to result in larger and
longer-lasting treatment gains in studies of other behavioral treatments for youth
(Gearing et al., 2013). Long-term follow-up data from a subset of treatment
responders from the CBIT trials also provides indirect evidence for the utility
of the generalization and mastery approach employed in CBIT. Espil and col-
leagues (2022) identified and reassessed 80 of the 126 participants from the
original trials 11 years posttreatment (on average) and found that CBIT
responders were more likely than PST responders to achieve partial or full
remission of symptoms (67% versus 0%, respectively), with no differences
between groups with respect to the use of adjunctive intervention in the 11-year
interim (Espil et al., 2022). While promising, additional research is clearly needed
to understand the relative role of the various HRT/CBIT treatment components in
the maintenance and durability of treatment gains, especially given the tendency
for tics to naturally improve over time for most patients.

Psychoeducation and Other Credible Ancillary Components

Several additional credible components are often incorporated into treatment to
enhance therapeutic outcomes or as ancillary techniques to minimize the impact
of tics on functioning. For example, psychoeducation is often provided to
ensure that patients have an accurate understanding of their TD, to provide
a rationale for treatment, to reduce stigma, and to correct common myths and
misunderstandings about TDs that could decrease treatment engagement and
 Tic Disorders 353

expectations (Cox et al., 2019). Cognitive restructuring, emotion regulation

strategies, collaborative problem solving, and mindfulness-based techniques
have also shown promise as ancillary or stand-alone techniques for reducing
tic-related impairment, distress, and self-stigma (McGuire et al., 2015; Reese
et al., 2015). Mindfulness strategies, in particular, could theoretically serve to
increase interoceptive awareness and urge tolerance, which might enhance
patients’ ability to identify and tolerate premonitory urges (Reese et al.,
2015); however, this remains speculative. Although there is insufficient evi-
dence to consider these techniques to be credible components, they have
generally been shown to be efficacious behavior change techniques and fit
within the biobehavioral conceptual model of TDs, though more research is
needed to understand their incremental benefit, if any.

Approaches for Youth

Approaches to treating tics in children largely parallel those used with adults
(Woods et al., 2008; Verdellen et al., 2011b). For example, as noted earlier, the
standard CBIT protocol has been shown to be efficacious for reducing tics in
children ages 8–17 years (Piacentini et al., 2010). The primary difference
between adult and child CBIT protocols is the involvement of parents when
treating children. In addition, research has shown that compliance with home-
work activities early in the course of treatment predicts treatment response in
youth receiving CBIT (Essoe et al., 2021). As such, the child-focused protocol
has an increased emphasis on early homework compliance and motivation. For
example, reward programs are typically employed to reinforce attending ses-
sions, active participation during sessions, and completing homework (Woods
et al., 2008), though it is unclear whether parental involvement or extrinsic
reward programs influence compliance or add incremental benefit. Further, an
adapted version of CBIT, referred to as CBIT-Junior, is a developmentally
modified protocol for children as young as five. CBIT-Junior contains several
developmental modifications to increase understanding and make tic suppression
practice easier, and has an increased emphasis on parental involvement in
treatment (Bennett et al., 2020). A small open pilot study with 15 youth with
TDs found that CBIT-Junior was effective for reducing tics, with response rate,
symptom reduction, and maintenance of treatment gains similar to those reported
in the larger child CBIT trial (Bennett et al., 2020), though larger randomized
controlled efficacy trials are needed. ERP has also been shown to be efficacious
in children, with many of the same modifications described for CBIT-Junior
(e.g., increased parental involvement and developmentally tailored language;
Mateu et al., 2018).
354 Kirsten Bootes, Emily Braley, and Michael B. Himle

Other Variables Influencing Treatment

Assessment and Diagnosis
The sole features that differentiate the primary TD diagnoses, the types of tics present
(motor, vocal, or both) and the duration of symptoms since initial onset (more or less
than one year) are important for diagnosis but have little practical relevance for
treatment. Both motor and vocal tics have been shown to respond to treatment, and
age of tic onset did not moderate or predict treatment response in the CBIT trials
(Sukhodolsky et al., 2017). A thorough assessment of TDs and common comorbid
conditions is essential for differential diagnosis, treatment planning and prioritization,
and outcome monitoring. Identification of comorbid conditions that might interfere
with the treatment of tics is particularly important prior to initiating treatment. At
a minimum, it is essential to carefully assess for the presence of comorbid attention-
deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and
depressive and anxiety disorders, as these are exceptionally common in TDs and can
complicate the treatment of tics (see section on “Comorbidity”). Several psychomet-
rically sound structured clinical interviews and symptom measures are available for
this purpose. A comprehensive assessment of tics is also strongly recommended to
inform the course of treatment and specific intervention components, and to monitor
treatment outcomes. For example, information regarding the sequence of complex tics
and understanding a patient’s degree of awareness of their tics and premonitory urges
can be useful for planning HRT. The most widely used assessment measures for TDs
are the Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989) and the
Premonitory Urge for Tics Scale (PUTS; Woods et al., 2005). The YGTSS is
a semistructured clinician-administered rating scale that contains a checklist of
common motor and vocal tics; anchored ratings of the number, frequency, intensity,
complexity, and interference caused by motor and vocal tics (rated separately to create
a 0–50 Total Tic Score [TTS]); and a global rating of tic-related impairment. The
PUTS is a brief self-report measure that asks the patient to rate the presence and
strength of premonitory urges. A 25% decrease on the YGTSS-TTS has been shown
to predict a clinically meaningful response to treatment (Jeon et al., 2013), and higher
premonitory urge ratings have been shown to predict poorer response to CBIT
(Sukhodolsky et al., 2017).

Comorbidity
Psychiatric comorbidity is exceptionally common in TDs. Large international clinical
samples have shown that that up to 85% of patients report a lifetime history of at
least one comorbid condition, with over half experiencing multiple comorbidities
(Freeman et al., 2000; Hirschtritt et al., 2015). ADHD (35–60%) and OCD (30–60%)
are particularly prevalent; mood, anxiety, and personality disorders are also common
 Tic Disorders 355

(Hirschtritt et al., 2015; Robertson et al., 2018). The high rate of psychiatric comor-
bidity in TDs has several implications for treatment. First, prioritizing treatment
targets can be challenging, as it is often the case that both tics and comorbid symptoms
uniquely contribute to distress and impairment, and the symptoms can interact in
complex ways (e.g., anxiety can exacerbate tics, and tics can be a source of anxiety).
Second, it can sometimes be difficult to differentiate tics from comorbid symptoms.
For example, complex tics can sometimes be difficult to differentiate from compul-
sions. These factors can make it challenging to decide what treatment to utilize (e.g.,
HRT versus cognitive and behavioral techniques for OCD). Finally, it is our clinical
experience that comorbid symptoms can complicate the delivery of treatments for
tics. For example, inattention, distractibility, and impulsivity can interfere with HRT.
Likewise, unmanaged depression and/or anxiety can decrease treatment motivation,
compliance, and treatment expectations, which have been shown to predict response
to CBIT (Essoe et al., 2021; Sukhodolsky et al., 2017). While a secondary analysis of
the CBIT trials found that comorbidity status did not moderate treatment response in
children or adults, the presence of an anxiety disorder did predict less improvement in
tic severity at posttreatment (Sukhodolsky et al., 2017). It is important to note,
however, that patients were excluded from those studies if they had unmanaged
comorbidity requiring more immediate treatment, raising questions about the gener-
alizability of the findings to patients with more severe comorbid symptoms.

Demographics
To date, few studies have examined the association between demographic or cultural
variables and treatment outcomes for tics, and the vast majority of existing treatment
studies have been conducted with predominantly White, non-Hispanic samples.
Understanding the impact of cultural variables in the treatment of tics and the
development and testing of culturally informed protocols is sorely needed, as the
limited information that is available suggests there may be important cross-cultural
differences in how tics and behavioral approaches to treatment are viewed (Stiede
et al., 2021). In addition, factors such as lack of awareness of effective treatment
options, misperceptions about behavioral approaches to tic treatment, access to
trained providers, and the cost and time associated with treatment are commonly
cited barriers to receiving CBIT, suggesting that TD-related health literacy, socioec-
onomic status, and factors related to healthcare access are worthy of additional
research (Woods et al., 2010).

Medication
Several effective medication options are available for treating tics and are often
used alongside behavioral therapies, especially for those with severe and/or
impairing tics. Typical and atypical neuroleptics have been shown to produce
356 Kirsten Bootes, Emily Braley, and Michael B. Himle

the most robust tic suppression, but their use is often limited by adverse side
effects (Weisman et al., 2013). Alpha-2 adrenergic agonists have also shown to
be moderately effective for reducing tics, especially for those with comorbid
ADHD, and are generally better tolerated (Weisman et al., 2013). Several other
novel therapeutic agents are currently under investigation (Quezada & Coffman,
2018). Head-to-head comparisons of medication and behavior therapy (or their
combination) have not been conducted with adults. Importantly, secondary
analysis of the CBIT trials found that medication status moderated treatment
response, with a smaller between-group effect size (CBIT vs. PST) for those on
tic-suppressing medications (Sukhodolsky et al., 2017). This effect was largely
accounted for by the fact that patients who were on alpha-2 agonists showed
a greater response to PST. However, participants not on tic-suppressing medica-
tions were more likely to show a positive response to CBIT than those on tic-
suppressing medications. Reasons for these findings are unclear. Speculatively, it
is possible that these findings are accounted for by group differences in pre-
medication tic severity, differences in patient characteristics among those who
are and are not prescribed medication, or that some tic-suppressing medications
interfere with CBIT (Sukhodolsky et al., 2017).

Conclusion
Behavioral approaches to tic management have been shown to be effective for
reducing tics in both adults and children. The intervention packages with the
strongest support are HRT, CBIT (which includes HRT as a primary compo-
nent), and ERP. Although these treatment packages have important procedural
differences, they share a set of theoretically driven components designed to
reduce tics and associated impairment. The primary credible components of
treatments for tics include techniques for increasing tic awareness, teaching
and facilitating tic suppression, the identification and modification of environ-
mental factors known to exacerbate tics, strategies to increase motivation and
treatment compliance, and techniques to promote generalization and maintenance
of treatment gains. Several additional therapeutic elements, including psycho-
education, relaxation training, relapse prevention, homework compliance, social
support, and behavioral reward programs, are also commonly included as part of
treatment. The development and testing of culturally adapted protocols, strat-
egies for enhancing treatment outcomes, and a better understanding of how to
effectively and efficiently treat psychiatrically complex cases are important
directions for future research.
 Tic Disorders 357

Box 19.1 Treatment Format

Treatment for tics have primarily been developed and tested as individually delivered,
face-to-face protocols with therapeutic sessions dispersed across several weeks.
However, alternative delivery modalities and formats have started to emerge. Several
studies have shown that CBIT and ERP can be effectively delivered via telehealth
technologies, with high rates of patient satisfaction and treatment effect sizes similar to
those reported with in-person delivery (Capriotti et al., 2023; also see Woods et al.,
2023 for a review). A few small, uncontrolled studies have also examined the feasibility
and efficacy of intensively delivered CBIT (delivered over the course of four days to two
weeks) and have found treatment response rates and symptom reduction similar to
what has been reported in studies utilizing the standard 10-week protocol (Blount et al.,
2014; Kennedy et al., 2016). However, to date, there have been no controlled studies
directly comparing intensive delivery to the standard CBIT protocol, and studies with
longer follow-up periods are needed to understand if treatment gains following
intensive delivery are durable. Group-delivered HRT and CBIT protocols have also been
tested in several small randomized controlled trials with children. These studies have
generally shown that group-delivered CBIT is more effective than education-only
control conditions for decreasing motor tics but not vocal tics (Yates et al., 2016;
Zimmerman-Brenner et al., 2022). It is not known why vocal tics would be less
responsive to group-delivered CBIT. In the only adult study to date, Bekk and colleagues
(2023) treated 26 adults with tics using a group-delivered CBIT protocol and found
significant reduction in overall tic severity at posttreatment and 1-year follow-up;
however, this study lacked a control comparison group. In addition, similar to what has
been reported in studies of children, vocal tics showed a less robust response compared
to motor tics. Combining group and intensive protocols, Heijerman-Holtgrefe and
colleagues (2021) conducted an initial pilot study of a four-day intensive group-
delivered ERP protocol for 14 children with tics and found that 23% of patients were
rated as treatment responders at posttreatment and 54% were rated as responders at
2-month follow-up; however, symptom reduction was lower than has generally been
reported in studies utilizing the standard ERP protocol, and this study lacked a control
comparison condition. Finally, online self-help and hybrid online + therapist-support
versions of CBIT and ERP have also shown promise in initial studies, with response rates
and degree of tic reduction similar to those observed in the traditional in-person,
therapist-delivered protocols (Hollis et al., 2021; Rachamim et al., 2022). Although
these alternative delivery formats are potentially promising avenues for addressing
known dissemination and utilization barriers for treatment for tics (e.g., lack of access to
trained therapists; Woods et al., 2010), additional studies examining their efficacy,
acceptability, and durability of treatment gains are needed, especially in adults.
358 Kirsten Bootes, Emily Braley, and Michael B. Himle

Useful Resources

Books
• McGuire, J. F., Murphy, T. K., Piacentini, J., & Storch, E. A. (2018). The clinician’s guide to
treatment and management of youth with Tourette syndrome and tic disorders. Elsevier.
• Verdellen, C. W. J., van de Griendt, J. M. T. M., Kriens, S., & van Oostrum, I. (2011). Tics:
Therapist manual. Boom Publishers.
• Woods, D. W., Piacentini, J. C., Chang, S. W., et al. (2008). Managing Tourette syndrome:
A behavioral intervention for children and adults. Oxford University Press.

Websites
• European Society for the Study of Tourette Syndrome: www.essts.org
• Tourette Association of America: www.tourette.org
• Tourettes Action: www.tourettes-action.org.uk

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 20
Couples Discord
Matthew D. Johnson and Erin F. Reto

Unlike most of the chapters that precede this one, the goal of couple therapy usually is
not the treatment of a disorder found in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5-TR; American Psychiatric Association, 2022). Rather, the
target of couple therapy is the improvement of a couple’s intimate relationship. By
“intimate relationship” we mean a close relationship that, at minimum, has the
potential for sex – relationships such as those experienced by couples who are dating,
living together, or married. We are not referring to other close relationships, such as
between other family members, friends, or business partners. While there is some
evidence that couple therapy approaches can be used with other types of close
relationships and couple therapy has demonstrated efficacy in treating problems
beyond the relationship (e.g., psychopathology, physical ailments, and parenting),
the vast majority of the research – and our focus in this chapter – is on employing
couple therapy to improve intimate relationships.
Couple therapy tends to have two conceptual goals: (1) the prevention or treatment
of relationship distress and (2) the prevention of relationship dissolution. Relationship
distress is usually operationalized with self-report measures of relationship
satisfaction, relationship quality, or relationship adjustment (and is included in the
DSM-5-TR under Other Conditions that May be a Focus of Clinical Attention).
Psychometrically, these are essentially the same underlying concept, with distress
being the opposite of satisfaction (Balderrama-Durbin et al., 2015; Mattson et al.,
2013; Norton, 1983); therefore, for the purposes of this chapter, we will use the terms
“relationship distress” and “relationship satisfaction.” Relationship dissolution sim-
ply means a divorce for married couples and a break-up for unmarried couples.

Etiology and Theoretical Underpinnings of Treatment

There are several broad theories from which couple therapies have been derived
(Paolino & McCrady, 1978). All of the approaches that have been subjected to
research feature the ongoing exchange of behavior within the couple. In this sense,
364
 Couples Discord 365

one can make the case – as we do – that social learning theory is at least part of, if not
central to, all of the couple therapies that have any empirical support. In social
learning theory (Bandura, 1977), basic operant learning principles guide social
behaviors among people. In other words, social learning theory is based on the idea
that people modify each other’s behavior specifically through the rewards and pun-
ishments that follow those behaviors (Bandura, 1969). In couples, the theory posits
that relationship partners routinely and mutually reward and punish each other’s
behaviors. Dysfunction develops when problematic behaviors are rewarded and
desirable behaviors are punished. All forms of couple therapy to one degree or another
attempt to alter maladaptive learning that has taken place between partners. In other
words, in various ways, couple therapies try to reinforce adaptive interpersonal
behaviors while ignoring or punishing maladaptive interpersonal behaviors (Stuart,
1969).
These theoretical principles became the foundation for couple therapies designed to
prevent (Markman, 1979) and treat (Jacobson & Margolin, 1979; Stuart, 1980)
relationship distress. Not only were social learning theory and behavioral principles
eagerly adapted for couple therapy, they are widely accepted by many people in
WEIRD (Western, Educated, Industrialized, Rich, and Democratic; Henrich et al.,
2010) societies. The most shared article in The New York Times is one in which
a reporter covering animal trainers used the same operant learning techniques the
trainers were using on animals on her husband. In the article, she described how she
stopped inadvertently reinforcing her husband’s dysfunctional behaviors (Sutherland,
2006). Of course, most couples do not describe their problems as dysfunctional
learning problems, they describe them as “communication” problems. What is com-
munication if not the ongoing exchange of behavior within the couple, which rests at
the heart of social learning theory? It is understandable that couples and their therap-
ists find social learning theory appealing because the ongoing exchange of behaviors
is the most proximal and parsimonious means of connecting to a partner and assessing
the strength of that connection. Each of the couple therapies described herein relies to
one degree or another on this theoretical principle.

Brief Overview of Treatments

There are many approaches to couple therapy that have empirical support and have
been subjected to randomized controlled trials (RCTs); for a full review of these, see
Lebow and Snyder (2022), and for a meta-analysis, see Roddy and colleagues (2020).
For the purposes of this chapter, we focus on behavioral couple therapy and therapies
that developed out of it (i.e., what some have termed “third-wave” therapies).
As noted previously, in first-wave behavioral couple therapy the goal was to alter
the dysfunctional learning that has taken place between partners and to relearn more
functional behavioral patterns (Jacobson & Margolin, 1979; Stuart, 1980). RCTs of
366 Matthew D. Johnson and Erin F. Reto

behavioral couple therapy demonstrated improvement in partners’ relationship satis-

faction. A meta-analysis found that it was more effective (d = 0.59) than no-treatment
control groups (Shadish & Baldwin, 2005). However, fewer than half of couples
treated with behavioral couple therapy had improved to the point that they were no
longer different from couples who were not seeking treatment (Jacobson et al., 1984)
and thus considered successful. Of the couples successfully treated, only about 70%
maintained the improvement for two years (Jacobson et al., 1987); 15% of success-
fully treated couples dissolved their relationship within two years (Christensen et al.,
2006) and 30% dissolved their relationship within five years (Christensen et al.,
2010).
After publicly declaring that behavioral couple therapy was ineffective, Neil
Jacobson – one of the original developers of the intervention – collaborated with
Andrew Christensen to develop integrated behavioral couple therapy (IBCT;
Jacobson & Christensen, 1996). This approach, like other third-wave therapies,
combined elements of the behavioral approach with acceptance of some aspects of
their relationship and partner. Jacobson and Christensen then conducted a rigorous
two-site RCT comparing IBCT to behavioral couple therapy. After five years, recov-
ery rates were similar for both groups, as were the rates of couples who deteriorated
and divorced (Christensen et al., 2010). Thus, ICBT does not appear to be more
efficacious than behavioral couple therapy.
Another couple therapy approach that was gaining attention at the same time was
emotionally focused therapy (EFT; Johnson & Greenberg, 1995), which is described
by its developers as an attachment-based, experiential-humanistic, systemic interven-
tion (Greenman & Johnson, 2013). Nevertheless, the first stage in the EFT approach
involves “cycle de-escalation,” followed by a restructuring of couples’ interactions.
These are the core components of a behavioral approach. EFT leads to 39% of couples
being indistinguishable from nontreatment-seeking couples, 7% to improvement but
still below the satisfaction of nontreatment-seeking couples, 21% who experienced no
change, and 32% who experienced deterioration or dissolution (Beasley & Ager,
2019; Wiebe et al., 2017). In other words, the outcome research on EFT did not differ
substantially from that of behavioral couple therapy and IBCT.
Although there are other couple therapy approaches that have empirical support,
behavioral couple therapy, IBCT, and EFT are the three with a substantial body of
RCTs behind them. Other approaches that have been carefully researched, including
with outcome research, are as follows:
• Cognitive-behavioral couple therapy is very similar conceptually to behavioral couple ther-
apy, but with more of a focus on dysfunctional thoughts (i.e., second-wave). The outcome data
on this approach is similar to other behavioral approaches (Baucom et al., 2022).
• Insight-oriented couple therapy is based on the couple understanding the origin of their
problems. It yielded similar results to behavioral couple therapy initially and at six months
 Couples Discord 367

Box 20.1 Preventative Interventions

Preventative interventions for couples, often called couple relationship education

(CRE), were developed contemporaneously with behavioral couple therapy, with the
same fundamental principles (e.g., Gottman et al., 1976; Markman & Floyd, 1980). The
most widely studied of the CREs is the Prevention and Relationship Enhancement
Program (PREP). Developed by Howard Markman, PREP was designed to teach couples
how to communicate more effectively, especially while discussing topics on which
there is disagreement (Markman et al., 1994). Others have developed programs that
include acceptance, commitment, empathy, stress management, and relationship
maintenance (e.g., Bodenmann & Shantinath, 2004; Halford, 2011; Ragan et al., 2009;
Rogge et al., 2013). Nevertheless, all of these CREs have the goal of preventing declines
in satisfaction by teaching couples better ways to communicate and handle the
inevitable stresses on their relationships.
Meta-analyses of RCTs indicate that prevention programs have a small to medium
effect on communication (d = 0.44) and relationship quality (d = 0.36) immediately
after the program (Hawkins et al., 2008). The problem is that there are some indications
that CRE programs can have negative impacts on couples, such as leading some to feel
less safe in the relationship (e.g., Bir et al., 2012; Wood et al., 2014). The effects of CREs
on relationships in the subsequent few years are null (Johnson, 2012, 2013; Johnson &
Bradbury, 2015). A meta-analysis of CREs showed that effectiveness was predicted
neither by the type of skill being taught nor the rigor of the program (Hawkins et al.,
2012). In the end, couples not receiving CREs and states not pushing CREs fare no
worse than do couples participating in CRE programs or states with more CRE funding in
terms of divorce rates (Johnson, 2014). In conclusion, the prevention of relationship
problems through CREs lacks the effectiveness to be considered empirically supported.

following treatment (Snyder & Wills, 1989). In one study, it also had a substantially lower
divorce rate (3% compared with 38%; Snyder et al., 1991).

Despite the assortment of approaches to choose from, at this time IBCT and EFT
are the couple therapies with the most evaluation research behind them; however,
there is no reason to think that cognitive-behavioral couple therapy and insight-
oriented couple therapy would fare any differently (for efficacy reviews, see
Bradbury & Bodenmann, 2020; Roddy et al., 2020).

Credible Components of Treatments

As noted previously, meta-analyses of couple therapy support a large effect (d ≥ 0.80)
immediately following termination of treatment, with 60–72% of couples having
noticeably better relationship satisfaction. As for whether these improvements last,
here are five-year posttreatment data from a rigorous study: 31–33% of couples have
368 Matthew D. Johnson and Erin F. Reto

recovered; 13–19% have improved but are still distressed; 50–54% have not changed,
deteriorated, or dissolved their relationship (Christensen et al., 2010). Returning to the
meta-analytic findings, caution should be used in interpreting the efficacy studies of
couple therapy overall because of the heterogeneity in the study designs, sample sizes,
and characteristics, and the involvement of the developers of the treatments in the
evaluation studies. As with all evaluation studies, the degree to which placebo effects
inflate treatment effects is not known without an active control group. Most of these
studies only used a passive no-treatment group. With those qualifications and all
things being equal (which they never are), one could argue that distressed couples
seeking treatment with a competent therapist have a one-in-three chance of experien-
cing improvement that lasts for at least five years.
None of the therapeutic approaches have been declared the clear winner, therefore
the field is considering which components of couple therapy increase its impact.
Although these lines of research are ongoing, Bradbury and Bodenmann (2020)
identified the following components of couple therapy as having promising results.

Early Assessment of Goals and Commitment

Couple therapy is a bitter pill. By the time they call a therapist, many couples find
themselves in relationships that are very near the point of dissolution. As many as half
are already actively considering separation and feel hopeless about whether the
relationship can be salvaged (Doss et al., 2004). Assessing couples’ goals for treat-
ment in the initial appointments is essential to understanding the prognosis of therapy.
The IBCT model (Christensen et al., 2020) suggests meeting with couples conjointly
in the first session and splitting the second session into two individual sessions. This
allows therapists to assess the couples’ and individuals’ goals for treatment; commit-
ment to the relationship, including whether there are any ultimatums on the table (e.g.,
a secession to extramarital relationships); optimism/hopelessness for treatment; and
willingness to work on improving the relationship. This assessment (via interview and
self-report measures) provides important prognostic information because the rate of
relationship dissolution within six months of therapy is 10% for couples in which both
partners have the goal of improving the relationship, 45% if only one partner seeks
improvement, and 56% if both partners have the goal of determining whether the
relationship can be saved (Owen et al., 2012; see Baucom et al., 2015, for similar five-
year data). If one or both partners seem to be questioning the viability of the relation-
ship or have the goal of an amicable dissolution, there are other models of intervention
available, such as discernment counseling (Doherty et al., 2016) and planning for
divorce in couple therapy (Lebow, 2022). In the end, a careful assessment at the onset
of treatment is likely to enable either triaging couples poorly suited for couple therapy
or improved efficacy of couple therapy (for a more thorough review of couple
assessment, see Snyder & Balderrama-Durbin, 2022).
 Couples Discord 369

Measurement-Based Care
Assessment should not end at the onset of treatment; rather, ongoing assessment
with psychometrically validated instruments should continue through treatment.
The powerful force of confirmation bias makes it difficult for therapists to gauge
progress using their own observations of the couple. In individual psychotherapy,
research shows that session-by-session monitoring and feedback of symptoms
improves treatment outcomes (Lambert et al., 2018). In couple therapy, measure-
ment-based approaches allow for more precise prediction of couples who are not
benefiting from couple therapy (e.g., Pepping et al., 2015). In two studies in which
couples were randomly assigned to either session-by-session monitoring of treat-
ment progress and alliance versus treatment as usual, the couples in the measure-
ment-based treatment had twice the rate of recovery or reliable improvement at the
end of treatment compared with the control group (Anker et al., 2009; Reese et al.,
2010). In summary, session-by-session data appears to improve couple therapy
outcomes, at least by the end of therapy. It is likely that the mechanism for this is
providing the therapist insights not easily gained from observation alone that
allow for course-correction during treatment (for more discussion of this, see
Halford et al., 2016).

Focusing on Positive Exchanges Between Partners

The two couple therapy approaches with long-term efficacy studies – IBCT and EFT –
show the same pattern: treatment effects fade over time (Christensen et al., 2010;
Wiebe et al., 2017). Christensen and colleagues found that, of the couples who
reliably improved or fully recovered by termination, half reverted to pretreatment
levels of relationship satisfaction or deteriorated even further. So, what distinguishes
the couples with lasting beneficial effects from those who deteriorate? It appears that
couples who maintain their relationship gains for five years posttreatment have greater
levels of problem-solving ability, display more positive behavior toward their partner,
reciprocate more positive behavior from their partner, and display more empathy
during conflict. In reviewing the list of five-year outcome predictors in the previous
sentence, note that these are all positive behaviors, whereas changes in negative
behaviors/skills and withdrawal/avoidance (either during treatment or measured
following treatment) did not predict five-year outcomes (Baucom et al., 2015;
Baucom et al., 2011). These findings, which are consistent with basic longitudinal
marital research (Johnson et al., 2005), offer hope that more of a focus on positive
skills and behaviors may allow couples to sustain the benefits of treatment for the
long-term. This is particularly challenging for therapists given couples’ reasonable
focus on addressing the negative interactions that brought them to therapy initially,
but it is likely worth rising to this challenge. Even if this challenge is met,
370 Matthew D. Johnson and Erin F. Reto

understanding how to focus on positive exchanges is fraught with the potential for
partners to dismiss positive acts because their partner is just doing what the therapist
told them to do; therefore, we explore some of the techniques from EFT and IBCT
with promising findings.
In both EFT and IBCT, improvements in relationship satisfaction appear
linked to in-session emotional responses, intimate disclosures and responsive
affiliative statements, and discussion of attachment issues. While the exact
procedures are beyond the scope of this chapter, therapists work to soften the
emotion of an aggrieved partner. As part of this, the therapist attempts to elicit
the aggrieved partner’s expression of a desire for closeness that in turn may
lower the defenses of the other partner and bring that person back into the
conversation (Wiebe et al., 2017). In different studies, this process has covaried
concurrently with session-by-session increases in relationship satisfaction and in
attachment security (Johnson & Whiffen, 1999; McKinnon & Greenberg, 2017;
Moser et al., 2018). In these tactics, therapists are explicitly attempting to
change expressions of affect from anger, contempt, and fear to affect that is
vulnerable, warm, and affiliative (Christensen et al., 2020; Schade et al., 2015;
Zuccarini et al., 2013).

Other Variables Influencing Treatment

Assessment of Intimate Partner Violence
Initial and ongoing rigorous assessment has been demonstrated to enhance
immediate and long-term efficacy. In this section, we focus on the assessment
of intimate partner violence (IPV) as essential to determining whether couple
therapy is indicated. The common belief among therapists is that IPV is not
a homogeneous phenomenon, but rather that it falls into distinct categorical
groups. The belief in an IPV typology, such as those proposed by Michael
Johnson (1995) and Amy Holtzworth-Munroe (Holtzworth-Munroe & Stuart,
1994) is widely accepted. However, there is scant evidence to support these
theories (Alexander & Johnson, 2023; Alexander & Johnson, under review) and
no validated assessment instrument that distinguishes them (Alexander et al.,
2021). Our recommendation is to ask about violence with both partners present,
then conduct a brief interview with each partner individually and administer the
HITS: a validated four-item measure that stands for Hurt, Insulted, Threatened,
and Screamed (Sherin et al., 1998). If there is a low level of violence (e.g.,
pushing or slapping), it is worth administering a validated couple-based IPV
intervention (Heyman & Schlee, 2003); however, if the violence is serious with
a high potential for lethality, it is recommended that the victim(s) become
unavailable to the perpetrator (de Becker, 1997).
 Couples Discord 371

Comorbidity
Relationship satisfaction is so strongly correlated with mental health that all but one of
the 11 most common mental illnesses tend to be comorbid with relationship distress
(Whisman, 2007), a finding consistent across racial and ethnic groups (McShall &
Johnson, 2015). Therefore, it is no surprise that, although the goal of couple therapy is
typically to improve relationship quality, it can be effectively used to reduce symp-
toms of comorbid illnesses (Meis et al., 2013). As the efficacy of couple-based
approaches to treating psychopathology has become better known, the acceptance
of it as a treatment has grown.
The mental illness for which couple therapy has been studied the most is depres-
sion. The efficacy of couple therapy approaches to depression has been described
and reviewed with meta-analyses (e.g., Barbato & D’Avanzo, 2020). Importantly,
there appears to be no clear differences between couple therapy and various effica-
cious individual psychotherapies for depression, but couple therapy has the added
benefit of being more efficacious than individual therapy at treating relationship
distress. This is particularly notable because a systematic review of the research
evidence on the comorbidity of depression and relationship distress led to the
conclusion that “summating across the evidence obtained from research using
correlational, genetically informed, and intervention methods, we conclude that
relationship distress is a causal risk factor for depression” (Whisman et al., 2021,
p. 250).
More and more diagnoses are demonstrating improved or as-good-as efficacy by
employing couple-based therapies instead of individual treatment. For example,
alcohol and drug problems are also a frequent target for couple-based interventions.
A meta-analysis of RCTs of alcohol abuse treatments found that couple-based
interventions were more efficacious than individual-based treatment (and again
increased relationship satisfaction; Powers et al., 2008). As the role of relationships
in the etiology and treatment of various forms of psychopathology becomes more
evident, we expect to see couple therapy used more widely with more mental health
disorders.

Demographics
There are some couple-based interventions that have been adapted for different
developmental stages and couples experiencing distinctive stressors. Most of the
adaptations that have had some outcome data collected tend to be primary or
secondary interventions. For example, a cognitive-behavioral secondary interven-
tion was designed for low-income African American couples with children. In this
in-home intervention, couples received instruction on how to work together to
address stressors likely to impact them (e.g., racism). An RCT of the project
revealed that the vast majority of the couples completed all six sessions, with treated
372 Matthew D. Johnson and Erin F. Reto

Box 20.2 Self-Directed and Brief Programs

With the onset of the pandemic, telemedicine and video therapy have become the
norm and widely accepted. Much has been written about the ways in which this will
enable more people to access these services. There were some couple-based
interventions that preceded the pandemic that have rigorous data. Initial work suggests
that self-directed programs have comparable effects with in-person programs (e.g.,
Braithwaite & Fincham, 2014; Zemp et al., 2017). For example, OurRelationship is an
interactive web-based program marketed as a “relationship counseling alternative.” It
has many of the components of in-person couple therapy, including a self-assessment
stage, a goal-setting stage, a problem-identification stage, an understand-the-problem
stage, and, finally, a resolution stage that employs acceptance and problem solving.
Couples also participate in four coaching sessions in which they can ask questions,
review progress, and tweak the program (Doss et al., 2013). In an RCT of
OurRelationship with 300 couples who were initially distressed, treated couples
reported greater satisfaction at termination compared with a waitlist control condition
(d = 0.69), and 57% improved their relationship satisfaction, 36% had no change, and
7% deteriorated (Doss et al., 2016). These effects were maintained a year following
treatment and appear to be beneficial for parenting as well (Doss et al., 2020; Doss
et al., 2019; Roddy et al., 2021). It is also worth noting that a brief two-session in-person
couple therapy program also led to demonstrable reductions in marital distress
(Córdova et al., 2014). Based on these data, it appears that online or minimal
interventions may be as effective as traditional in-person couple therapy while also
greatly expanding access to care.

couples reporting better satisfaction, communication, and parenting relationships at

17- and 25-month follow ups compared with the couples who received a workbook
on relationship communication (Barton et al., 2017; Barton et al., 2018; Lavner
et al., 2019, 2020). The success of this intervention points to the benefits of taking
stressors associated with distinct demographic characteristics into account in couple
therapy.
The transition to parenthood is a particularly challenging time for couples (Doss &
Rhoades, 2017; Johnson, 2016). Unfortunately, a meta-analysis of specialized inter-
ventions for couples transitioning to parenthood revealed negligible effects on rela-
tionship satisfaction (d = 0.12) and small effects on communication (d = 0.29) over
one year (Pinquart & Teubert, 2010). However, there is evidence that couples with
several known risk factors for divorce benefit from couples-based interventions as
they transition to parenthood (Petch et al., 2012), and these benefits last more than two
years later (Heyman et al., 2019). Thus, there is still much to learn about tailoring
interventions for couples at particular life stages, particularly with regard to secondary
interventions.
 Couples Discord 373

Conclusion
Relationship problems are not only common but important. Overall life satisfaction is
most closely aligned with relationship satisfaction (Diener et al., 2000; Diener et al.,
1999), and it is associated with nearly everything we care about, including physical health
(e.g., Langhinrichsen-Rohling et al., 2011), mental health (Whisman, 2007), and job
performance (e.g., Forthofer et al., 1996; Leigh & Lust, 1988). Notably, many of these
associations appear to be causal, with relationship problems leading to other problems
(e.g., Whisman et al., 2021). So, what do we know about preventing and treating
relationship distress? We know that many couples will remain mostly happy and that
relationship education programs for these couples is probably unnecessary. Many other
couples have the deck stacked against them and will struggle to make their relationships
work because of their circumstances. We know that alleviating the stress in their lives is
more likely than therapy or relationship education programs to prevent relationship
dissolution (Johnson, 2013). Finally, we know that many other couples will become
distressed and fall into patterns of conflict or malaise in their relationship. The approaches
to couple therapy that have been empirically tested using rigorous methods offer some
hope for these couples. IBCT and EFT, with their focus on emotional connection and
acceptance, perform reasonably well in RCTs, and research on the efficacious mechan-
isms of change suggest that there are some common factors and principles at work across
couple therapeutic approaches. Common factors, such as the quality of the alliance
between patient and therapist, reliably predict outcomes in therapy (Cuijpers et al.,
2019) and this is true in couple therapy as well (Davis, 2022). Beyond these common
factors there are credible components of a science-based approach to couple therapy
outlined by Bradbury and Bodenmann (2020) as well as Christensen (2010). Some have
proposed a unified protocol for couple therapy with five common principles: “(a) altering
the couple’s view of the presenting problem to be more objective, contextualized, and
dyadic; (b) decreasing emotion-driven, dysfunctional behavior; (c) eliciting emotion-
based, avoided, private behavior; (d) increasing constructive communication patterns;
and (e) emphasizing strengths and reinforcing gains” (Benson et al., 2012, p. 25). To
varying degrees, science-based approaches to couple therapy incorporate all five prin-
ciples of the unified protocol. Based on the current empirical literature, couple therapists
would do well to heed these principles no matter the model they prefer to employ.

Useful Resources

• An approach to treating relationship distress by watching movies: www.rochester.edu/news/

divorce-rate-cut-in-half-for-couples-who-discussed-relationship-movies/
• An efficacious online self-directed couple therapy: www.ourrelationship.com/
• EFT, another efficacious couple therapy: http://iceeft.com/
• IBCT, an efficacious couple therapy: https://ibct.psych.ucla.edu/
374 Matthew D. Johnson and Erin F. Reto

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 21
Psychotherapy Relationships
John C. Norcross and Christie P. Karpiak

The patient–practitioner relationship constitutes the heart and soul of psychotherapy,

healing in and of itself. Second only to the client’s contribution, the therapy relation-
ship is the most powerful predictor of, and contributor to, successful outcomes. Even
when offered as a manualized intervention and delivered via electronic means,
therapy is invariably rooted in and dependent on that complex connection between
the client and therapist. As such, it warrants substantial attention in any scientific
compilation of evidence-based (or science-based) list of psychotherapy components.
The effectiveness of the multiple relationship factors cuts across theoretical orien-
tations (transtheoretical) and largely across client problems (transdiagnostic). The
research evidence on the relationship does not favor any single orientation; the
probability of a positive client–clinician relationship or a failure in that relationship
is not any more characteristic of one psychotherapy system than another. The rela-
tionship elements or components considered in this chapter have all been shown, in
dozens of individual studies and in rigorous meta-analyses, to associate, predict, and
contribute to success. Failure to provide these elements also predicts and contributes
to poor treatment outcomes, however measured (e.g., dropout, deterioration).
In this chapter, we review evidence-based psychotherapy relationships, primarily
with adults in individual treatment. We begin by defining our terms and diving into
effective relationship behaviors or components (what works). That is followed by
a few words on ineffective or discredited relationship behaviors (what does not
work). We then advance therapeutic and training practices based on this research
evidence. The chapter finishes with multiple caveats, concluding thoughts, and
useful resources.

Definitions
Many spirited and unproductive debates on psychotherapy fail to operationally define
their terms. Antagonists wind up speaking past one another, literally not on the same
page. Cases in point are the psychotherapy relationship and evidence-based practice.
381
382 John C. Norcross and Christie P. Karpiak

We will not commit the errors of undefined terms and unidentified contexts in this
chapter.
An operational definition of the therapeutic relationship is the feelings and atti-
tudes that therapist and client have toward one another, and the manner in which these
are expressed (Gelso & Carter, 1985, 1994). While this definition is quite general, it is
mercifully concise, theoretically neutral, and sufficiently precise.
The therapeutic alliance represents a part of the relationship, but only a part. In
fact, a pernicious error in the psychotherapy literature equates the totality of the
relationship with the therapeutic alliance. In part, this mistake occurs inadvertently
because the alliance is the most frequently measured and researched relationship
factor in the psychotherapy literature (Horvath et al., 2016). In part, too, this mistake
probably occurs intentionally to misrepresent and diminish the cumulative power of
the relationship (Norcross & Karpiak, 2023). Ironically, the alliance’s association
with psychotherapy success is not even the largest of the relationship factors, as
discussed shortly. Conflating the entirety of the therapy relationship with only the
alliance weakens the power of the therapeutic relationship empirically and clinically.
The short past of evidence-based practice (EBP) in behavioral/mental health
traces back to the 1980s, originally in Great Britain and then gathering steam in
Canada, the United States, and now around the globe (Norcross et al., 2017). The
early stirrings of the movement trace back to the United Kingdom and Archie
Cochrane’s (1979) article calling on medicine to assemble critical summaries of
science-based treatments that had proven effective according to randomized clinical
trials. Cochrane and others contrasted EBP with expert- or authority-based practice,
the latter lacking in solid research support and typically resulting in less effective
health care.
A consensual and concrete definition of EBP has emerged from the research
literature and professional organizations. Adapting a definition from Sackett and
colleagues, the Institute of Medicine (2001, p. 147) defined evidence-based medicine
(EBM) as “the integration of best research evidence with clinical expertise and patient
values.” The American Psychological Association (APA) Task Force on Evidence-
Based Practice (2006, p. 273), beginning with this foundation and expanding it to
mental health, defined EBP as “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture, and preferences.”
We use the latter as our operational definition throughout.
Several core features of EBPs become manifest in this definition. First and fore-
most, EBPs rest on three pillars: available research; clinician expertise; and patient
characteristics, culture, and preferences. By definition, the wholesale imposition of
research without attending to the clinician or patient is not EBP; conversely, the
indiscriminate disregard of available research is not EBP. Second, the definition
requires integrating these three evidentiary sources. The integration flows seamlessly
and uncontested when the three evidentiary sources agree; it becomes complicated
 Psychotherapy Relationships 383

and contested when the three sources disagree. Third, not all three pillars stand equal:
Research assumes priority in EBP. Clinicians begin with research and then integrate
with their expertise and patients. Fourth and final, compared to EBM, the patient
assumes a more active, prominent position in EBPs in behavioral health and addic-
tions. “Patient values” in EBM rise to the status of “patient characteristics, culture,
and preferences” in behavioral health EBPs.

Evidence-Based Therapy Relationships

The centrality of the therapy relationship has been highlighted since the origins of
modern psychotherapy. Sigmund Freud described the operation of transference and
countertransference, and psychoanalytic scholars developed a rich literature on the
relationship. Among the foundational constructs are the establishment of a positive
working or therapeutic alliance (Bordin, 1979; Luborsky, 1976) and the management
of negative countertransference (Singer & Luborsky, 1977). The real relationship,
characterized by realism and genuineness, was emphasized later by psychodynamic
therapists (Greenson, 1967; Gelso et al., 2019). All three of these elements have
subsequently proven effective in psychotherapy according to the research evidence
(Table 21.1; Norcross & Lambert, 2019).
Carl Rogers’s legacy includes the three relational facilitative conditions for thera-
peutic change: empathy, positive regard, and genuineness/congruence (Rogers,
1957). Two of Rogers’s facilitative conditions are demonstrably effective and the
third probably effective based on the meta-analyses (Table 21.1; Norcross & Lambert,
2019). A dedicated scientist, Rogers established psychotherapy process–outcome
research, modeling how to scientifically examine the association between specific
therapist behaviors and client responses to understand not just whether psychotherapy
works but how it works.
Early cognitive-behavioral formulations of the therapy relationship emphasized it
as a precondition of change, the soil that enables treatment methods to work, as
opposed to a healing process in and of itself. Therapist and patient were to work
together, akin to a student–teacher relationship, establishing rapport, cultivating
positive expectations, and jointly determining treatment goals (Beck et al., 1979).
Recent meta-analyses support the salubrious link between collaboration, goal con-
sensus, and positive expectations and successful psychotherapy (Table 21.1; Norcross
& Lambert, 2019).
Subsequent generations of practice and research on the therapy relationship have
emphasized transtheoretical conceptualizations (as opposed to theory specific) and
research evidence (as opposed to clinical lore or authority). In this context, three
American Psychological Association (APA) Interdivisional Task Forces were con-
vened to identify, compile, and disseminate therapy relationships that were evidence
based (Norcross, 2002; Norcross, 2011; Norcross & Lambert, 2019). The Task Force
384 John C. Norcross and Christie P. Karpiak

Table 21.1 Summary of meta-analytic associations between relationship components

and distal psychotherapy outcomes (adapted from Norcross & Lambert, 2019; © Norcross &
Lambert)

# of # of Effect size Consensus on

studies patients evidentiary strength
Relationship element (k) (N) r d or g
Alliance in individual 306 30,000 0.28 0.57 Demonstrably
adult psychotherapy + effective
Alliance in child and 43 3,447 0.20 0.40 Demonstrably
adolescent therapy effective
Alliances in couple and 40 4,113 0.30 0.62 Demonstrably
family therapy effective
Collaboration 53 5,286 0.29 0.61 Demonstrably
effective
Goal consensus 54 7,278 0.24 0.49 Demonstrably
effective
Cohesion in group 55 6,055 0.26 0.56 Demonstrably
therapy effective
Empathy 82 6,138 0.28 0.58 Demonstrably
effective
Positive regard and 64 3,528 0.28 Demonstrably
affirmation effective
Collecting and 24 10,921 0.14–0.49 Demonstrably
delivering client effective
feedback
Congruence/ 21 1,192 0.23 0.46 Probably effective
genuineness
Real relationship 17 1,502 0.37 0.80 Probably effective
Emotional expression 42 925 0.40 0.85 Probably effective
Cultivating positive 81 12,722 0.18 0.36 Probably effective
expectation
Promoting treatment 24 1,504 0.12 0.24 Probably effective
credibility
Managing 9 392* 0.39 0.84 Probably effective
countertransference
Repairing alliance 11 1,318 0.30 0.62 Probably effective
ruptures

* Refers to the number of psychotherapists, not patients.

Note. In the behavioral sciences, an effect size (d or g) of 0.20 is generally considered a small
effect, 0.50 a medium effect, and 0.80 a large effect (Cohen, 2013).
 Psychotherapy Relationships 385

aimed, in addition, to heal some of the damage of the culture wars in psychotherapy
that unproductively pit treatment methods against therapeutic relationships.
In its third and most recent iteration, Psychotherapy Relationships that Work
(Norcross & Lambert, 2019; Norcross & Wampold, 2019) contains two volumes
of 30 meta-analyses of therapist and patient contributions to therapy effective-
ness. The strength of the scientific evidence is undeniable, and the field has
(mostly) matured past polarized positions (relationship vs. method) to consider
how all elements optimally operate and interact. Table 21.1 presents, from those
volumes, a summary of the meta-analytic associations between relationship
elements and distal (end of treatment) psychotherapy outcomes. In the following
section, we concentrate on those elements that have proven effective in individ-
ual psychotherapy with adults.

What Works
Alliance
The term alliance is not easily differentiated from several other relational
concepts; in the literature, the words “working,” “helping,” or “therapeutic”
often appear in conjunction with it (Fluckiger et al., 2019). An early tripartite
definition by Bordin (1979) emphasized (1) a warm emotional bond, (2) agree-
ment on respective tasks, and (3) consensus on treatment goals. A more recent
definition includes mutual collaboration between client and therapist on goals
and tasks of psychotherapy, along with the therapeutic bond between the dyad
(Del Re et al., 2021). Alliance is interpersonal – therapist and client both
contribute to it – but the ability to form an alliance with an array of clients is
a therapist characteristic that can be learned (Ackerman & Hilsenroth, 2003;
Muran & Eubanks, 2020).
A meta-analysis of more than 30,000 clients found a moderate, but extremely
robust, association between the alliance and outcome in adult individual psychother-
apy (d = 0.57; Fluckiger et al., 2019). The alliance relates to, predicts, and contributes
to psychotherapy success. To a lesser extent, success in therapy also strengthens the
relationship.
Likewise, with a few wrinkles, the alliance in youth psychotherapy works.
Across 43 studies of child and adolescent therapy (3,447 clients and parents),
there was a moderate effect size between alliance and treatment outcome
(d = 0.40; Karver et al., 2019). Importantly, the strength of the alliance–outcome
relation did not vary with the type of treatment. Further, the effect size, or
clinical impact, of dual alliances – therapist with youth, therapist with parent –
was identical. Both the therapist–youth and therapist–caregiver alliance matter
mightily.
386 John C. Norcross and Christie P. Karpiak

The average effect size for the alliance in couples/family therapy is in the same
range (0.62), based on 40 studies (Friedlander et al., 2019), as is the impact of the
alliance in psychopharmacological treatment, based on 8 studies (Totura et al., 2018).
The alliance emerges in the ongoing relationship between therapist and client, and
accurate measurement of the alliance at any point during the course of therapy
probably requires collecting information from both (or all) participants. Most studies
indicate that the client rating is the better predictor of treatment outcome than therapist
or observer ratings, but all information proves valuable. Alliance measures completed
by the client can be used by a therapist or supervisor to track the development of this
vital competency and predictor of therapy outcome.

Goal Consensus and Collaboration

These two relational components are present across theoretical orientations and are
sometimes considered part of the therapeutic alliance. Indeed, both are commonly
assessed for research purposes via measures of the alliance, completed separately by
clinician and client. Goal consensus refers to the agreement between the therapist and
the client about the targets of their work together and how to achieve them. A large
body of research documents the vital role this factor plays in treatment outcome
(d = 0.49; Tryon et al., 2019). Collaboration is the active mutual engagement of the
therapist and client around the work of therapy. Research also shows that collabor-
ation is substantially associated with treatment outcome, with an effect size (d) of 0.61
(Tryon et al., 2019).

Empathy
The term empathy is widely used in the common vernacular to refer to a strong
emotional response to the situation of another, and in popular use is often conflated
with sympathy or compassion. For clarity, we use Rogers’s (1980, p. 85) definition
as “the therapist’s sensitive ability and willingness to understand the client’s
thoughts, feelings and struggles from the client’s point of view.” Empathy can be
assessed, according to Barrett-Lennard (1981), as “(a) the therapist’s empathic
resonance with the client, (b) the observer’s perception of the therapist’s expressed
empathy, and (c) the client’s experience of received therapist empathy” (Elliott
et al., 2019, p. 248).
Empathic responding is one of the strongest and best-supported contributors to
outcome (Elliott et al., 2019). Starting with the groundbreaking research of Carl
Rogers, decades of evidence now attest to its value, with meta-analytic effect sizes
ranging between moderate to large (d = 0.58), from 82 high-quality studies. Even
better, the skills and basic stance of empathic understanding can be practiced in
everyday relationships outside of a real or simulated therapy situation (see Miller,
2018), as long as others in these relationships are willing and able to provide feedback.
 Psychotherapy Relationships 387

Affirmation and Validation

Therapist positive regard for the client (and expression of that regard, including
through affirmation) is another relationship factor originally investigated by Carl
Rogers. As with empathy, positive regard has been the subject of much research,
with its effect on psychotherapy outcome falling in the moderate range (d = 0.57),
based on 64 studies of quality appropriate for inclusion in a meta-analysis (Farber
et al., 2019).
Like empathy, the terms positive regard and affirmation are easily misunderstood –
mistaken for simple compliments, shallow praise, or other concrete tactics (e.g.,
preceding requests for compliance). In fact, positive regard is the therapist’s genuine
nonpossessive liking and expressed appreciation for the client as a unique person.
This strengthens the client’s sense of agency and self. To contribute to outcome, this
regard must be made evident to the client through words and nonverbals. Therapists
can express on a regular basis that they value, care about, and believe in the client,
ideally over the course of treatment. However, it does not need to be (and probably
could not be) experienced by the therapist at every moment across treatment with any
given client (Farber et al., 2019).

Congruence/Genuineness and Real Relationship

This pair of relational factors includes the last of the three Rogerian core conditions
(empathy, unconditional positive regard, and congruence/genuineness) and a concept
from the psychodynamic literature: the real relationship. Both have accumulated
sufficient evidence to be classified as effective.
Congruence/genuineness has both intrapersonal and interpersonal features, mean-
ing it is both a personal characteristic of the therapist as well as a quality of the
therapeutic interaction. When congruent, therapists’ actions and behaviors not only fit
their words but also who they are as a person – their values and identity – exuding
groundedness, thoughtfulness, and genuineness. In short, they are real, not phony,
distracted, or playing a role. Studies of this relational component show a moderate
association with treatment outcome, making it a reliable contributor to therapeutic
success (d = 0.46; Kolden et al., 2019).
The real relationship is composed of both genuineness and realism. It’s “the
personal relationship between therapist and patient marked by the extent to which
each is genuine with the other and perceives/experiences the other in ways that befit
the other” (Gelso, 2014, p. 119). In contrast to the alliance, it refers to a subset of
therapist–client interactions not directly focused on the tasks. These interactions are
taken at face value in the here and now. A meta-analysis based on 17 studies and
1,502 patients revealed a large effect between the real relationship and client success
(d = 0.80; Gelso et al., 2019).
388 John C. Norcross and Christie P. Karpiak

Emotional Expression
Although emotion is obviously core to psychotherapy, organized research on the subject
is quite recent. That evidence shows that the facilitation, experience, and expression of
client emotion in session are strongly correlated with treatment outcome (d = 0.85;
Peluso & Freund, 2019). Contributions to this research base come from a wider range of
theoretical orientations than do the components reviewed thus far. Because of this
variability, the definition of emotional expression is less precise and has failed to achieve
consensus in the field. One essential and simple clarification: what is not being refer-
enced here is the “expressed emotion” from family process and relapse prevention
research with serious mental illnesses, where reducing expressed emotion is the goal.
Of all the relational elements, emotional expression is possibly the one that can
most easily go astray in the absence of a clear plan. Treatment model and case
formulation help determine which emotions to address, where a particular emotional
expression fits into the therapeutic endeavor, and what to do with it – in other words,
how to attend to and make therapeutic use of emotion versus allowing the session to
deteriorate into an unfocused rant, wallow, or self-attack.

Repair of Alliance Ruptures

Ruptures are problems or strains in the collaborative relationship between client and
therapist related to treatment goals, agreement on the tasks of therapy, or the emo-
tional bond (Eubanks et al., 2019). Two main types occur in session: (1) withdrawal,
in which the client moves away from the therapist and the work; and (2) confrontation,
in which the client moves against the therapist by expressing anger or dissatisfaction.
Although the term rupture may connote a dramatic breakdown, many studies point to
subtle tensions and minor misalignments as markers.
Therapist efforts to repair alliance ruptures can be overt or indirect. Either way,
research shows attending to them improves treatment outcomes. A meta-analysis of
11 studies, involving 1,318 clients, revealed that repair of alliance ruptures in individ-
ual therapy is moderately to strongly associated with outcome (d = 0.62). That is,
addressing ruptures works; ignoring them does not.
Repairing ruptures proves valuable for all psychotherapists, but especially for
therapists with less experience and training in negotiating the therapeutic alliance
(Eubanks et al., 2019). Moderator analyses revealed that rupture resolutions training
is more effective for cognitive-behavioral therapists, many of whom have not
received explicit training in processing relationship dynamics with their clients.

Collection of Client Feedback

In collecting feedback from patients – or the more recent term routine outcome
monitoring (ROM) – psychotherapists inquire directly about the patient’s progress
on a regular basis, compare those data to benchmarks or norms, address the progress
 Psychotherapy Relationships 389

(or lack thereof) directly in session, and, in some cases, offer clinical support tools to
identify obstacles and adapt future sessions. A dozen or so ROM systems are now
available, but most of the controlled research has employed the Outcome
Questionnaire and the briefer PCOMS (Partners in Change Outcome Monitoring
System) feedback systems. A meta-analysis of 24 controlled trials (on more than
10,000 patients) conducted on those systems (Lambert et al., 2019; Table 21.1) found
that feedback or ROM produced variable but salutatory effects (between 0.14 and
0.49) on distal treatment outcomes. A subsequent and larger meta-analysis (de Jong
et al., 2021) on 58 studies, encompassing more than 20,000 patients, reported an
overall d of 0.15.
Collecting feedback or conducting ROM is thus slightly effective for all patients
but more effective for patients not on track in treatment or at risk of an unsuccessful
outcome. ROM, in fact, reduces the risk of patient dropout by 20–25% (de Jong et al.,
2021; Lambert et al., 2019). All these are additive effects to conducting standard
therapy.

Overall
The scientific conclusion emerges that there is a robust, consistent association
between these core relational elements and client improvement. On average, the
correlation (r) is about 0.25–0.30. That translates to an effect size (d) of about
0.55 and indicates that clients receiving psychotherapy characterized by high
degrees of empathy, regard, and the like will experience a decided advantage
over clients that receive (or perceive) relatively lower degrees of those relation-
ship attributes.
Although this estimate of treatment effects may seem rather modest, bear in mind
the large number of complex variables that contribute to treatment outcomes, espe-
cially clients’ contributions and life events that exist before and during the therapeutic
encounter (Lambert et al., 1992). Also bear in mind that the average effect size (d)
between psychotherapy and no psychotherapy hovers about 0.85; any single relational
behavior in Table 21.1 comes in at an impressive 0.55.
It would probably prove advantageous to both practice and science to sum the
individual effect sizes in Table 21.1 to arrive at a total of relationship contribution to
treatment outcome, but reality is not so accommodating. Neither the research studies
nor the relationship elements contained in the meta-analyses are independent; hence,
the amount of variance accounted for by each element cannot be simply added to
estimate the overall contribution. For example, the correlations between empathy and
therapeutic alliance are as high as 0.70 (Watson & Geller, 2005). The intercorrelations
between the person-centered conditions are also high: in an early research review on
client-centered conditions empathy correlated 0.53 with positive regard, 0.62 with
congruence, and 0.28 with unconditionally (Gurman, 1977). Unfortunately, the
390 John C. Norcross and Christie P. Karpiak

degree of overlap between all the measures (and therefore relationship elements) is
not available but is bound to be substantial.
Despite the overlap in relational elements, the best scientific estimates of relation-
ship effects are reliable and robust. The therapeutic relationship contributes as much,
and probably more, to client outcomes than the particular treatment method. The
effect sizes for relationship behaviors (Table 21.1) of 0.39–0.72 are higher than the
effect sizes of 0–0.20 attributable to different treatment methods found in bona fide
comparisons (Wampold & Imel, 2015). Although we deplore the mindless dichotomy
between relationship and method in psychotherapy, we also need to publicly proclaim
what decades of research has discovered: The relationship can heal.

What Does Not Work

Translational research is both prescriptive and proscriptive; it tells us what works and
what does not (Norcross et al., 2017). Here, we highlight those practitioner relational
behaviors that are ineffective, perhaps even hurtful, in psychotherapy (Karpiak &
Norcross, 2022; Norcross & Karpiak, 2023).
Of course, we could simply reverse the effective behaviors identified in the meta-
analyses (Table 21.1) to identify ineffective qualities of the therapeutic relationship.
What does not work, for example, are poor alliances, paucity of collaboration, and
inadequate efforts at empathy. The ineffective practitioner will not seek nor be
receptive to client feedback on progress and relationship, will ignore alliance ruptures,
and will not promote their patients’ emotional expression. “One doesn’t have to
operate with great malice to do great harm,” warned Charles Blow. “The absence of
empathy and understanding are sufficient.”
Another means of identifying ineffective qualities of the relationship is to scour the
research literature for clinician behaviors frequently associated with negative out-
comes and premature discontinuation (e.g., Hardy et al., 2019; Swift & Greenberg,
2012). Here are several relational behaviors that therapists should avoid according to
the Task Forces review of that research (Norcross & Lambert, 2019):
♦ Confrontations. Controlled research trials, particularly in the addictions field, consistently
find that a confrontational style proves ineffective. In one review (Miller et al., 2003),
confrontation was ineffective in all 12 identified trials. And yet it persists. By contrast,
expressing empathy, rolling with resistance, developing discrepancy, and supporting self-
efficacy characteristic of motivational interviewing have demonstrated large effects in
a small number of sessions (Lundahl et al., 2013).
♦ Negative processes. Client reports and research studies converge in warning therapists to
avoid comments or behaviors that are experienced by clients as hostile, pejorative, critical,
rejecting, or blaming (Binder & Strupp, 1997). Therapists who attack a client’s dysfunc-
tional thoughts or relational patterns need, repeatedly, to distinguish between attacking the
person versus their behavior. When negative processes ensue, then repairing alliance
 Psychotherapy Relationships 391

ruptures is amongst the most easily applied skills and strongest relationship behaviors
documented in psychotherapy (Eubanks et al., 2019; Table 21.1).
♦ Assumptions. Psychotherapists who assume or intuit their client’s perceptions of relation-
ship satisfaction and treatment success frequently misjudge these aspects. By contrast,
therapists who formally measure and respectfully inquire about their client’s perceptions,
via feedback or ROM, frequently enhance the alliance and prevent premature termination
(Lambert et al., 2019).
♦ Therapist-centricity. A recurrent lesson from process–outcome research and the associated
meta-analyses is that the client’s perspective on the therapy relationship best predicts
outcome. Psychotherapy that relies on the therapist’s observational perspective alone,
while valuable, does not predict outcome as accurately. Therefore, privileging and moni-
toring the patient’s experience of the relationship prove central.
♦ Rigidity. By inflexibly and excessively structuring treatment, psychotherapists risk
empathic failures and inattentiveness to clients’ experiences. Such a therapist is likely to
overlook a breach in the relationship and mistakenly assume they have not contributed to
that breach. Dogmatic reliance on particular relational or therapy methods, incompatible
with the client, imperils treatment (Ackerman & Hilsenroth, 2003).
♦ Cultural arrogance. Arrogant impositions of therapists’ cultural beliefs in terms of gender,
race/ethnicity, sexual orientation, and other intersecting dimensions of identity are cultur-
ally insensitive and demonstrably less effective (Soto et al., 2019). By contrast, therapists’
expressing cultural humility, offering adapted treatments, and emphasizing cultural respon-
siveness markedly improve client engagement, retention, and eventual treatment outcome.

We can optimize therapy relationships by simultaneously using what works and

studiously avoiding what does not work.

Cautions and Caveats

In valuing the therapeutic relationship, it becomes deceptively easy to overplay the
impact of that relationship in treatment (Norcross & Lambert, 2014). “It’s all the
relationship” is a frequent (and inaccurate) refrain among many trainees and some
practitioners. The Task Force repeatedly urged restraint and balance in disseminating
its meta-analytic findings, pointedly concluding that “The therapy relationship acts in
concert with treatment methods, patient characteristics, and other practitioner qual-
ities in determining effectiveness; a comprehensive understanding of effective (and
ineffective) psychotherapy will consider all of these determinants and how they work
together to produce benefit” (Norcross & Lambert, 2019, p. 632).
Historically, the polarized psychotherapy community rarely found the middle
ground in valuing the therapy relationship in context; contemporarily, most psycho-
therapists avoid the unproductive schism of relationship versus method and frame the
therapeutic relationship in comprehensive, scientific contexts. Multiple lines of evi-
dence suggest that humans (including patients) hold two major dimensions of social
perception, often called warmth and competence (Eisenbruch & Krasnow, 2022). The
392 John C. Norcross and Christie P. Karpiak

relational warmth of the therapist is typically prioritized by patients over therapist

competence (e.g., Swift & Callahan, 2010). Fortunately, the choice is not binary or
exclusive. The most effective therapists regularly manifest both relational warmth and
technical competence (Castonguay & Hill, 2017; Seewald & Rief, 2022).
The research on these relational elements features additional cautions. The meta-
analytic results in Table 21.1 probably underestimate the true effect of the relationship
due to the responsiveness problem (Kramer & Stiles, 2015; Stiles et al., 1998). It is
a problem for researchers but a boon to practitioners, who flexibly adjust the amount
and timing of relational behaviors in psychotherapy to fit the unique individual and
singular context. Effective psychotherapists responsively provide varying levels of
relationship elements in different cases and, within the same case, at different
moments. This responsiveness tends to confound attempts to find naturalistically
observed linear relations of outcome with therapist behaviors (e.g., empathy,
ROM). As a consequence, the reported statistical association between therapy rela-
tionship and outcome cannot always be trusted and tends to be lower than it actually
is. By being clinically attuned and flexible, psychotherapists ironically make it more
difficult in research studies to discern what works (Norcross & Lambert, 2019).
Nor has the research generated a definitive list of what works in the therapy
relationship. We have neither completed the search nor exhausted the relationship
behaviors associated with therapy success. Insufficient controlled research exists to
draw conclusions at this juncture on many other relationship behaviors advocated by
practitioners.
As the evidence base of therapist relationship behaviors develop, we will know
more about their effectiveness for particular circumstances and conditions. A case in
point is the meta-analysis on collecting client feedback or conducting ROM. The
evidence is clear that adding formal feedback/ROM helps clinicians effectively treat
patients at risk for deterioration and that adding some form of clinical support tools to
assist clinicians boosts its effectiveness. But for most of these relational elements, we
do not yet know for whom and when they prove effective.
The strength of the therapy relationship also depends in some instances on the
client’s principal disorder. The moderator analyses occasionally find some relation-
ship elements less efficacious with some disorders, usually substance abuse, severe
anxiety, and eating disorders. Most moderator analyses usually find the relationship
equally effective across disorders, but that conclusion may be due to the relatively
small number of studies for any single disorder and the resulting low statistical power
to find actual differences. And, of course, it gets more complicated as patients
typically present with multiple, comorbid disorders.
Finally, we emphasize that, with a couple of exceptions (collecting feedback,
repairing alliance ruptures), the meta-analyses reported the association and prediction
of the relationship element to psychotherapy outcome. These were overwhelmingly
correlational designs, showing that more of, say, collaboration, emotional expression,
 Psychotherapy Relationships 393

Box 21.1 Therapy and Training Practices

Review of the research evidence led the APA Interdivisional Task Force (Norcross &
Lambert, 2019) to advance several recommendations for clinical practice and training.
Practitioners are encouraged to:

♦ make the creation and cultivation of the therapy relationship a primary aim of
treatment. This is especially true for relationship elements found to be demonstrably
and probably effective.
♦ assess relational behaviors (e.g., alliance, empathy, cohesion) vis-à-vis cut-off scores
on popular clinical measures in ways that lead to more positive outcomes.
♦ assess and responsively attune psychotherapy to clients’ cultural identities (broadly
defined).
♦ monitor patients’ satisfaction with the therapy relationship, comfort with responsive-
ness efforts, and response to treatment. Such monitoring leads to increased oppor-
tunities to re-establish collaboration, improve the relationship, modify technical
strategies, and investigate factors external to therapy that may be hindering its effects.
♦ use concurrently evidence-based relationships and evidence-based treatments
adapted to the whole patient as that is likely to generate the best outcomes in
psychotherapy.

In turn, training programs are encouraged to:

♦ provide competency-based training in the demonstrably and probably effective

elements of the therapy relationship.
♦ train students in assessing and honoring clients’ cultural heritages, values, and beliefs
in ways that enhance the therapeutic relationship and inform treatment adaptations.
♦ develop criteria for assessing the adequacy of training in evidence-based therapy
relationships and responsiveness.

and positive regard were associated with improved patient success. Of the relationship
behaviors reviewed in this chapter, only two (client feedback/ROM, alliance ruptures)
have addressed disaggregation by means of RCTs and only one (alliance in individual
therapy; Del Re et al., 2012) by other statistical means. And it turns out the evidence is
strong that it is the therapist that is important: therapists who generally form stronger
alliances generally have better outcomes, but not vice versa (Wampold et al., 2012). It
is largely the therapist’s contribution, not the patient’s, that relates to therapy outcome
(Baldwin et al., 2007; Wampold & Imel, 2015). Put differently, for most of these
relationship elements, we know with certainty that they characterize, positively
correlate with, and predict successful psychotherapy. But that does not necessarily
mean that they are therapist contributions. Another type of causal linkage is still
needed.
394 John C. Norcross and Christie P. Karpiak

Conclusion
How to improve the outcomes of psychological treatments? Follow the scientific
evidence; follow what contributes to treatment outcome as reviewed in this chapter.
Begin by leveraging the patient’s resources and self-healing capacities; create and
cultivate a therapy relationship characterized by these effective elements; avoid use of
ineffective and discredited relational behaviors; responsively personalize to the
patient’s characteristics, personality, and worldviews. That’s evidence-based therapy
relationships.
All treatment, all health care, all methods are embedded within a relational context.
Not only is there a deep synergy between a treatment method and a therapeutic
relationship, but one does not exist without the other. This point was convincingly
made decades ago in Winnicott’s observation that there is no such thing as a baby
without a mother. Effective psychotherapy cannot, and does not, exist without
a relationship.
The future of mental health services portends the integration of science and
service, of the instrumental and the interpersonal, of the technical and the
relational in the EBP tradition (Norcross et al., 2016). We can imagine few
practices in mental health that can confidently boast that they seamlessly
integrate “the best available research with clinical expertise in the context of
patient characteristics, culture, and preferences” (APA Task Force, 2006,
p. 273) as well as cultivating and customizing the powerful therapy relation-
ship. As Carl Rogers (1980) compellingly demonstrated, there is no inherent
tension between a relational approach and a scientific one. Science can and
should inform us about what works in psychotherapy – be it relational or
otherwise.

Useful Resources

• Norcross, J. C., & Lambert, M. J. (Eds.). (2018). Evidence-based psychotherapy relation-

ship III (special issue). Psychotherapy, 55(4), 303–537.
• Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that
work. Volume 1: Evidence-based therapist contributions (3rd ed.). Oxford University
Press.
• Norcross, J. C., & Wampold, B. E. (2019). (Eds.). Psychotherapy relationships that work.
Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press.
• Norcross, J. C., & Karpiak, C. P. (2023). Relationship factors. In S. D. Miller, D. Chow,
S. Malins, & M. A. Hubble (Eds.), Field guide to better results: Individualizing a deliberate
practice. American Psychological Association.
• Society for the Advancement of Psychotherapy (APA Division of Psychotherapy). (2020).
Teaching and learning evidence-based relationships: Interviews with the experts. society
forpsychotherapy.org/teaching-learning-evidence-based-relationships.
 Psychotherapy Relationships 395

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 Postscript
Evaluating Treatments with the Science-Based Tolin Criteria:
A Call to Action
Cassandra L. Boness, Stephen Hupp, and David F. Tolin

The chapters in this book offer a glimpse of what effective therapies look like, but
we are just at the beginning of fully realizing what science-based therapy will
become. As described in Chapter 1, the Society of Clinical Psychology (SCP;
Division 12 [D12] of the American Psychological Association) provided the first
major comprehensive framework for identifying efficacious psychological treat-
ments. Within this framework – sometimes referred to as the “Chambless criteria” –
the highest designation that an empirically supported treatment (EST) can be given
is to be officially characterized as well-established (Chambless & Hollon, 1998;
Chambless & Ollendick, 2001) and informally described as having strong research
support (www.psychologicaltreatments.org). Table 22.1 provides a summary of the
psychological treatments for adults that have achieved this highest level of support
(for a similar table about treatments for youth, see Hupp & Hupp, 2023).
As can be gleaned from the table, the majority of ESTs fall within the behavioral
and cognitive traditions. Moreover, the blended approach of cognitive-behavioral
therapy (CBT) – and its many variants – has frequently been identified as being well
established. These time-limited behavioral and cognitive therapies have been particu-
larly well suited to being investigated by using randomized controlled trials (RCTs),
which many consider to be the “gold standard” for determining treatment efficacy.
However, it’s important to recognize that the emphasis on RCTs has been criticized
for not being applicable to “real-world” settings (Beutler, 1998; Goldfried & Wolfe,
1996, 1998; Gonzales & Chambers, 2002; Norcross, 1999; Seligman, 1996), and it
has been correctly noted that many patients seeking psychological treatment will
deviate from the RCT sample in some important ways (Fensterheim & Raw, 1996;
Westen et al., 2004b). Whereas RCTs commonly exclude patients for “comorbid”
psychiatric conditions (Westen & Morrison, 2001), clinic patients frequently meet
criteria for multiple disorders, making it difficult to isolate a single disorder
(Goldfried & Eubanks-Carter, 2004; Wachtel, 2010; Westen et al., 2004a). The
operationalizing of psychotherapeutic procedures in the form of manualized treat-
ments allowed for greater consistency across therapists, created some minimal
399
400 Cassandra L. Boness, Stephen Hupp, and David F. Tolin

Table 22.1 Well-established empirically supported treatments: Chambless criteria

Disorder Well-established treatments

Attention deficit/ Cognitive-behavioral therapy
hyperactivity
disorder
Schizophrenia and other Assertive community treatment
severe mental Cognitive-behavioral therapy
illnesses Cognitive remediation
Family psychoeducation
Social learning/token economy programs
Social skills training
Supported employment
Bipolar disorder Psychoeducation (mania)
Systemic care (mania)
Family-focused therapy (depression)
Depression Behavioral activation
Cognitive therapy
Cognitive behavioral analysis system of psychotherapy
Cognitive-behavioral therapy (for people with diabetes)
Interpersonal psychotherapy
Mindfulness-based cognitive therapy
Problem-solving therapy
Self-management/self-control therapy
Anxiety disorders Cognitive and behavioral therapies (generalized anxiety disorder)
Cognitive-behavioral therapy (panic disorder; social anxiety)
Exposure therapies (specific phobias)
Obsessions-compulsive Cognitive-behavioral therapy
disorder Exposure and response prevention
Posttraumatic stress Cognitive processing therapy
disorder Prolonged exposure therapy
Seeking safety (with substance use disorders)
Pain Acceptance and commitment therapy (chronic)
Cognitive-behavioral therapy (back; head; irritable bowel)
Multicomponent CBT (fibromyalgia; rheumatologic)
Eating disorders Cognitive-behavioral therapy (bulimia; binge eating disorder)
Family-based treatment (anorexia; bulimia)
Interpersonal psychotherapy (bulimia; binge eating disorder)
Weight management Behavioral weight management
Insomnia disorder Cognitive-behavioral therapy
Paradoxical intention
Relaxation training
Sleep Restriction therapy
Stimulus Control therapy
 Postscript 401

Table 22.1 (cont.)

Disorder Well-established treatments

Substance and alcohol Behavioral couples therapy (alcohol)
use disorder MI, MET, and MET+CBT (mixed substances)
Seeking safety (mixed substance)
Borderline personality Dialectical behavior therapy
Relationship distress Emotionally focused couples therapy

Note: A version of this table was originally published in Hupp & Hupp (2023), created in 2023,
and influenced by several pages from the website for the Society of Clinical Psychology (SCP)
and several systematic reviews. MI = motivational interviewing; MET = motivation
enhancement treatment; CBT = cognitive-behavioral therapy.

standards of practice, and allowed practitioners and patients alike to more clearly
understand what was to be done. This process, however, raised eyebrows among
many (e.g., Fonagy, 1999; Levant, 2004; Norcross, 1999), with some suggesting that
these manuals overestimate the degree of homogeneity among patients with
a particular diagnosis, forcing a “one-size-fits-all” approach (Wachtel, 2010).
Others criticized treatment manuals as a “straightjacket for a talented therapist”
(Goldfried & Eubanks-Carter, 2004, p. 670). Aware of these criticisms, some
researchers have worked toward including participants with comorbidities, offering
treatment manuals that allow for greater flexibility, and prioritizing investigations in
real-world settings.
As described in Chapter 1, the updated Division 12 EST guidelines – sometimes
referred to as the “Tolin criteria” (Tolin, McKay, et al., 2015) set out to encourage
greater emphasis on research in real-word settings. Other priorities of these newer
criteria also include a demonstration of meaningful outcome improvement, lasting
treatment gains, and other contextual factors such as the identification of active
ingredients. Since the publication of these new EST criteria, the evidence base for
several psychological treatments has been formally evaluated according to these
standards. Psychological treatments that have been evaluated in coordination with
the SCP include exposure and response prevention for obsessive-compulsive disorder
(Tolin, Melnyk, et al., 2015), CBT for insomnia disorder (Boness et al., 2020), CBT
for substance use disorder (Boness et al., 2023), contingency management for drug
use (Pfund et al., 2022), and CBT for gambling harm (Pfund et al., 2023). Additional
evaluations for psychological treatments are currently in progress. Table 22.2 pro-
vides a summary of the results of these reviews, and a current list of completed and in-
progress evaluations is maintained by the SCP’s Committee on Science and Practice.
Treatments evaluated with the “Tolin criteria” are also located on the SCP’s website.
402 Cassandra L. Boness, Stephen Hupp, and David F. Tolin

Table 22.2 Empirically supported treatment status: Tolin criteria

Treatment Target Treatment Recommendation

Obsessive-compulsive Exposure and response Strong recommendation
disorder prevention
Insomnia disorder Cognitive-behavioral therapy Strong recommendation
Substance use disorders Cognitive-behavioral therapy Strong recommendation
Contingency management Strong recommendation
(drug use)
Gambling harm Cognitive-behavioral therapy Strong recommendation

Note: The possible levels of recommendation are: very strong recommendation, strong
recommendation, and weak recommendation.

As shown in the table, the treatments evaluated with the Tolin criteria to date have
received a strong recommendation – but not a very strong recommendation. Moreover,
very few treatments have been evaluated at all. Thus, the need for rigorous research
persists, and the door is open for many more reviews. Our call to action is this: Consider
conducting a treatment evaluation using these criteria and submitting that evaluation to
Division 12 for consideration as an EST. To do so, a good first step would be to read the
brief manual: The Society of Clinical Psychology’s Manual for the Evaluation of
Psychological Treatments Using the Tolin Criteria (Boness et al., 2021), available for
free on the SCP website (https://div12.org/psychological-treatments/). The manual
describes the next steps, including how to submit a letter of intent to the SCP’s
Committee on Science and Practice.
Of course, evaluating the empirical support for a treatment with the Tolin criteria is
no small undertaking. To aid in the process, there have been attempts to manualize the
application of the criteria and offer tools for simplifying the process (Boness et al.,
2021). Although there are required elements of evaluating a treatment with the
Division 12 Criteria, there is no one “right” way, and specific practices may vary
across evaluation teams (e.g., the decision to statistically combine effect sizes or not,
which review quality tool to use). The lack of a single “right” way to conduct these
evaluations can be a challenge for some teams, particularly in cases where the team
lacks sufficient expertise to deviate from the manual.
In our opinion, adequately evaluating the evidence for a particular psychological
treatment requires a diverse team with both content and methodological experience. It
is valuable to have a team member with expertise in a given treatment for the
particular disorder in question (e.g., CBT for insomnia disorder) as well as a team
member with expertise in systematic review methodology, including meta-analyses.
In ideal circumstances, it can also be helpful to have a team member with expertise in
additional or adjacent treatments for the same disorder (e.g., brief behavioral treat-
ment for insomnia disorder), particularly if that person has less allegiance to the
 Postscript 403

treatment being evaluated compared to other team members. Teams might even seek
out a member who is critical of the treatment under evaluation as they can bring
a healthy level of skepticism to the process.
One of the greatest resources to engage when undertaking a systematic review of any
type is a librarian, particularly one with subject matter expertise. Librarians can help
formulate comprehensive search strategies and conduct literature searches to ensure all
relevant reviews are captured for the evaluation. In some cases, they may also be able to
help guide other steps in the evaluation, including the selection of software for screening
reviews and extracting data as well as the selection of standardized instruments for
evaluating review quality. We strongly advise consulting a librarian early and often in
the evaluation process, and even formally including them as a team member. Whether
a librarian is included or not, staying organized throughout the evaluation process is
critical for transparent reporting and rigorous treatment evaluation.
A final word of advice when conducting these evaluations is to take the consider-
ation of contextual factors seriously. Contextual factors include considering features
such as how the current treatment’s effect size compares to other well established
treatments; whether the current treatment offers an advantage in cost, efficiency, or
practicality; evidence that the treatment is effective across diverse individuals, patient
populations, and settings; whether the treatment has been studied by a wide array of
researchers without strong allegiance to the treatment; and evidence linking the
treatment to the purported mechanism of change. These are critical to consider in
treatment evaluations because they have the potential to influence the overall treat-
ment rating (i.e., weak, strong, very strong) and can provide insight into what
additional work might be needed to strengthen the evidence base for the treatment.
Although evaluating treatments with the Tolin criteria may seem like a massive
undertaking, with the right team and robust systems for staying organized, these
evaluations are feasible to complete. Evaluation teams are not required to pursue
publication of their evaluations, but we strongly encourage them to for the sake of
dissemination. As more evaluations are completed, the criteria can also be updated
and refined to ensure that the evidence base for psychological treatments is being
evaluated with rigor, further supporting the dissemination of effective treatments and
the improvement of mental health care for all people.

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 Index

Please note: page numbers in italic type indicate tables

acceptance and commitment therapy (ACT), 2 treatment process, 253
anxiety disorders, 51 UK NICE guidelines, 258
chronic pain, 127–128 useful resources, 259
depressive disorders, 18 youth approaches, 255
acupressure point tapping, 5–6 antisocial personality disorder (AsPD)
adult antisocial behavioral syndrome (AABS), 246 assessment and diagnosis, 256
Alive Inside: A Story of Music and Memory comorbidity, 256
(Rossato-Bennett), 229 diagnostic criteria, 246–247
Alternative model of personality disorders (AMPD), etiology, 247
273, 274 lifetime prevalence estimates, 247
Alzheimer’s Disease, 219 long-term prognosis, 258
American Psychological Association, xiii medication trials, 257
clinical practice guidelines for depression, 13 prevalence, 271
children and adolescents, 20 research recommendations, 257
on demographic considerations, 22 risk factors, 248
patients with severe depression, 21 theoretical underpinnings of treatment, 248–249
ethical guidelines, 7 therapeutic approaches, 272–273
Anglin, D. M., 113 anxiety disorders, 47
anorexia nervosa (AN) acceptance and commitment therapy, 51
characteristics, 139, 140 assessment and diagnosis, 54
See also eating disorders. comorbidity, 21, 55, 354
anosmia, 227 core features, 47
antisocial behavior, 246–259 credible components of treatments, 50–53
assessment and diagnosis, 256 addressing cognitive bias, 53
comorbidity, 256 cognition
credible components of treatments, 251–254 hypothesis test, 52
context of treatment, 254 increased relevance, 52
developing treatment readiness, 252 exposure, 51–52
posttreatment life, preparation for, 254 intersection of cognition and, 52
relapse prevention, 254 demographic considerations, 55
skills development, 252 etiology and theoretical underpinnings of treatment,
demographic considerations, 257 47–48
etiology and theoretical underpinnings of treatment, intolerance of uncertainty, 53
247–249 medication, 55–56
indigenous treatment approaches, 258 overestimation of threat, 53
medication, 257 overview of treatments, 48–49
overview of treatments, cognitive-behavioral cognitive therapy, 49
approaches, 249–251 emotion-focused coping strategies, 49

406
 Index 407
exposure therapy, 48 etiology and theoretical underpinnings of treatment,
perfectionism and, 53 305–307
personality traits and, 56–57 medication, 322
practice guidelines, 55 overview of treatments, 307–309
research support, 50 prevalence estimates, 304
useful resources, 58 useful resources, 323
youth approaches, 54 youth approaches, 319–320
anxiety, median age of onset for adolescents, 41 See also intellectual developmental disorder (IDD).
assertive community treatment, psychosis, 285 avoidant personality disorder, 272
assertiveness training, 224 Azrin, N. H., 163
comparison study, 19
attention-deficit/hyperactivity disorder (ADHD), Bachman, G. A., 178
329–339 Bækkelund, H., 108
assessment and diagnosis, 336 Balderrama-Durbin, C., 368
characteristics, 329 Barrett-Lennard, G. T., 386
commonalities with borderline personality disorder, Basco, M. R., 34
331 Bateman, A., 270
comorbidity, 336, 354 Bauer, M. S., 36
credible components of treatments Beck, A., 34, 39, 82
cognitive reframing, 335 bee-sting therapy, 6
learning theory, 332–333 behavioral activation
mindfulness, 335 comparison study, 19
planning and prioritizing, 334 depressive disorders, 15
self-instruction via “mantras,” 334 race/ethnicity and, 15
temporal discounting, 333–334 behavioral skills training (BST), ASD, 309
time estimation, 333 behavioral strategies, eating disorders, 145–147
demographic considerations, 337 Bekk, M., 357
differentiating from bipolar disorder, 41 Belli, H., 113
etiology and theoretical underpinnings of treatment, Bergeron, S., 180
329–330 binge eating disorder (BED)
medication, 337–338 characteristics, 139
overview of treatments, 330–331 See also eating disorders.
cognitive-behavioral therapy, 330–331, 399 Binik, Y. M., 178
effects on co-occurring conditions, 332 bipolar disorder, 30–43
goal, 329 assessment and diagnosis, 40–41
dialectical behavior therapy, 331 comorbidity, 41
useful resources, 339 credible components of treatments, 36–40
youth approaches, 335–336 cognitive restructuring, 39
Atwood, M. E., 142 psychoeducation, 37, 40
autism spectrum disorder (ASD), 304 relapse prevention, 39
assessment and diagnosis, 320–321 social support, 40
characteristics, 304 demographic considerations, 42
comorbidity, 321–322 etiology and theoretical underpinnings of treatment,
co-occurring mental health conditions, 308 31–32
credible components of treatment, 309–319 medication, 42
behavioral skills training, 309 overcoming treatment challenges, 38
cognitive-behavioral therapy, 313–314 overview of treatments, 32–36
differential reinforcement, 312 cognitive-behavioral therapy, 32–35
employment-related interventions, 317–319 research on CBT-BP, 37
functional communication training, 312–313 family-focused therapy, 35
mindfulness-based therapy, 314–315 systemic/collaborative care, 36
PEERS program, 315–316 relapse prevention, 39
prompting, 311–312 research therapists, 37
role playing, 310 sleep restriction and, 167
social skills interventions, 315–316 symptoms
task analysis, 310 according to DSM-5, 41
video modeling, 309–310 similarities in presentation to MDD, 30
408 Index
bipolar disorder (cont.) exposure, 126
useful resources, 43 mindfulness, 128–129
youth approaches, 40 pacing of activities, 126–127
Blow, Charles, 390 psychological flexibility, 129–130
Bodenmann, G., 368, 373 relaxation, 128
body dysmorphic disorder (BDD), 68–69 definition of pain, 122
Boesveldt, S., 227 demographic considerations, 131
Boness, C. L., xiii, 161 etiology and theoretical underpinnings of treatment,
borderline personality disorder 123–124
commonalities with ADHD, 331 medication, 132
credible components of treatments, 269–271 overview of treatments, 124–125
common factors, 269–270 prevalence, 122
emotion regulation, 270 somatic symptom disorder, 123
present-oriented focus, 271 useful resources, 132
differentiating from ADHD, 41 youth approaches, 130
ICD scoring dimensions, 274 Clark, D. M., 88
overview of treatments, 267–269 Claussen, A. H., 255
dialectical behavior therapy, 267–268 Cochran, S. D., 34, 39
general psychiatric management, 268 Cochrane, A., 382
mentalization-based therapy, 269 cognitive loss, 218–236
schema-focused therapy, 269 assessment and diagnosis, 231
STEPPS program, 268 care partners
transference-focused psychotherapy, 269 distress tolerance skills, 231
prevalence, 271, 276 interventions for, 221–222
self-injurious thoughts and behaviors in youth and, role of assertiveness training, 224
271 comorbidity
typical age of onset and duration, 266 medical conditions, 232
useful resources, 276 psychiatric conditions, 232–233
Bordin, E. S., 385 credible components of treatment, 223–231
Bornstein, R. F., 273 behavioral skills training, 221
Bradbury, T. N., 368, 373 cognitive reframing, 230–231
BrainHQ, 288 differential reinforcement, 229
Brand, B. L., 113 distress tolerance skills, 231
Bross, L. A., 310 for care partners, 231
Brotto, L. A., 182 function-based behavioral management, 226–231
bulimia nervosa (BN) meaningful events, access to, 229
characteristics, 139, 140 music, 229
See also eating disorders. navigating healthcare and education, 224–225
Burke, B. L., 199 problem-solving strategies, 225–226
Bush, S. S., 225 reducing vascular risk factors, 223–224
re-establishing behavioral chains/sequences,
Cachia, R., 314 228–229
Cannella-Malone, H. I., 306, 319 reminiscence therapy, 229
care coordination, psychosis, 292 sleep interventions, 227
Catrone, R., 312 social contingencies interventions, 230
Chambless criteria, xiv, 2, 5, 70, 177, 195, 399, 400 stimulus control interventions, 226–228
Chambless, Dianne, xiii systematic observations, 226
Chiang, K.-J., 34 demographic considerations, 233–234
Christensen, A., 366, 369, 373 distinction between cognitive decline and dementia,
Christie, H. J., 111 218
chronic pain, 122 etiology and theoretical underpinnings of treatment,
assessment and diagnosis, 130 219–220
comorbidity, 131 format and duration of interventions, 235
credible components of treatments, 125–130 foundational repertoires at risk of decline, 218
acceptance, 127–128 functional model, 219
behavioral goals, 125 medication, 234–235
cognitive skills training, 127 mild vs. major neurocognitive disorders, 218
 Index 409
overview of treatments, 220 diagnostic criteria, 246
prevalence, 218 skills deficits in, 250
research support, 222–223 Cooper, J., 307
social interactions, role of in rate of decline, 230 Coping Cat, treatment of anxiety disorders in youth, 54
training components, 221 couples discord, 364
treatment packages, 220–221 assessment of intimate partner violence, 370
useful resources, 235–236 comorbidity, 371
cognitive reframing couple relationship education (CRE), 367
ADHD, 335 credible components of treatments, 367–370
cognitive loss, 230–231 early assessment of goals and commitment, 368
cognitive remediation, schizophrenia, 288 focusing on positive exchanges, 369–370
cognitive restructuring measurement-based care, 369
bipolar disorder, 39 demographic considerations, 371–372
comparison study, 19 etiology and theoretical underpinnings of treatment,
depressive disorders, 17 364–365
sexual dysfunction, 179–180 goal of couple therapy, 364
tic disorders, 353 overview of treatments, 365–367
cognitive strategies, eating disorders, 147 parenthood and, 372
cognitive therapy preventative interventions, 367
anxiety disorders, 49 self-directed programs, 372
behavioral experiments, 71 useful resources, 373
efficacy of, 31 Craske, M.G., 51–52
OCD, 71–72 cultural competence, definition, 16
PTSD, 88–89
cognitive-behavioral analysis system of psychotherapy David, D., xiii, 115
(CBASP), 21 Davison, G. C., 5, 289
cognitive-behavioral therapy (CBT) dementia, WHO’s distinction between cognitive decline
adaptation strategies, 220 and, 218
ADHD, 330–331 dependent personality disorder, 273
antisocial behavior, 249–251 depression
ASD, 313–314 chronic pain and, 131
cognitive skills training for chronic pain, 127 disease burden, 11
components, 17 medical disorders associated with, 21
comparison, 19–20 prevalence in the US population, 11
cultural considerations, 15 protective factors, 12
dissociative disorders, 109 psychoeducation and, 39
eating disorders, 141–142 risk factors, 12
effects on depression, 222 depressive disorders, 11
historical perspective, 1 and the therapeutic relationship, 14
insomnia, 161, 401 assessment and diagnosis, 21
primary goal, 313 comorbidity, 21
psychoeducational focus in CBT-BP trials, 33 credible components of treatments, 14–20
SUDs, 195, 401 acceptance and commitment therapy, 18
“well-established” status, 399 behavioral activation, 15
cognitive-behavioral therapy for bipolar disorder cognitive restructuring, 17
(CBT-BP) comparing components, 19–20
overcoming challenges, 38 interpersonal targets, 19
overview of treatments, 32–35 mindfulness, 18
research, 37 problem solving, 17
treatment strategy, 31–32 cultural considerations, 15–16
cognitive-behavioral therapy for psychosis (CBTp), demographic considerations, 22
284–285 etiology and theoretical underpinnings of treatment,
collaborative care, bipolar disorder, 36 12–13
Colom, F., 40 learning model of depression, 12
Conant, E., 312 medication, 23
conduct disorder (CD) overview of treatments, 13–14
AsPD and, 246 persistent depressive disorder, 11, 21
410 Index
depressive disorders (cont.) relapse prevention, 148
sociocultural perspective, 14 social support, 146–147
“third wave” approaches, 13 demographic considerations, 149, 150–151
useful resources, 13 etiology and theoretical underpinnings of treatment,
youth approaches, 20–21 140–141
desensitization, sexual dysfunction, 181–182 lifetime prevalence, 139
dialectical behavior therapy (DBT) medication, 151
ADHD, 331 overview of treatments, 141–143
borderline personality disorder, 267–268 family-based treatment, 142–143
dissociative disorders, 110 interpersonal psychotherapy, 143
differential reinforcement useful resources, 152
ASD, 312 youth approaches, 148–149
cognitive loss, 229 Edinger, J. D., 163
disability-adjusted life years (DALYs), 11 Ehlers, A., 82, 88, 257
Diseth, T. H., 111 emotion regulation
dismantling research, role of in analyzing treatment borderline personality disorder, 268, 270
outcome data, 5 definition, 290
dissociative disorders, 105–115 psychosis, 290–291
access to treatment, 114 sexual dysfunction, 179–180
assessment and diagnosis, 111 tic disorders, 353
comorbidity, 113 emotional processing theory, 83
controversial nature of dissociative conditions, 107 empathy
demographic considerations, 113–114 psychotherapy relationships and, 386
DSM-5-TR definition, 105 role of in therapy outcomes, 289
emerging and promising treatments empirically supported treatments (ESTs)
cognitive-behavioral therapy, 109 Chambless criteria, 400
dialectical behavioral therapy, 110 cataloguing based on, xiv
dissociative disorders network program, 108–109 criticisms of initial criteria for, 3
phase-oriented treatment, 107–108 SCP’s role in conceptualizing and identifying, 2, 6
schema therapy, 111 the concept, 2–4
unified protocol, 110 the movement to define and identify, xiii
etiology and theoretical underpinnings of treatment, updated requirements, 3–4
106–107 employment-related interventions
medication, 114 ASD, 317–319
overview of treatments, 107 psychosis, 287–288
prevalence, 105 energy therapies, 6
research recommendations, 112 epilepsy, sleep restriction and, 167
useful resources, 115 Episodic Future Thinking (EFT), 334
youth approaches, 111 Espie, C. A., 163
distress tolerance skills, cognitive loss, 231 ethical guidelines, American Psychological
dolphin-assisted therapy, 6 Association, 7
Dorahy, M. J., 113 Evans, M., 33
D’Souza, R., 35 evidence-based practice (EBP)
Dubreucq, J., 315 core features, 382
Duffy, A., 41 definition, 4–5
historical perspective, 382–383
eating disorders, 139 evidence-based therapy relationships, 383–385
assessment and diagnosis, 149–150 excoriation, 68–69
body checking and body avoidance behaviors, 145 exposure therapy
comorbidity, 150 central feature, 48
credible components of treatments, 143–148 chronic pain, 126
behavioral strategies, 145–147 conceptual model, 67
cognitive strategies, 147 eating disorders, 145–146
exposure therapy, 145–146 OCD, 70
in-session weighing, 147 PTSD, 86–88
nutritional/dietary strategies, 144–145 exposure with response prevention (ERP)
psychoeducation, 143–144 common core of treatment packages, 68
 Index 411
conceptual model, 67 and anxiety disorders, 51
evaluation status, 70 and OCD, 67
meta-analyses, 67 insomnia disorder (ID), 159
eye movement desensitization and reprocessing assessment and diagnosis, 166
(EMDR), controversy over, 84 comorbidity, 167
credible components of treatments
Fairburn, C. G., 140 components requiring further research, 164
family therapy relaxation therapies, 163–165
bipolar disorder, 35 sleep restriction therapy, 163
eating disorders, 142–143 stimulus control, 162
psychosis, 286, 291 definition and DSM-5-TR criteria, 159
Fetkewicz, J. M., 112 demographic considerations, 167
Fisher, 310 etiology and theoretical underpinnings of treatment,
Five Factor Model of personality traits, 266 159–160
Foa, E. B., 51, 67, 73 intensive sleep retraining research, 164
Fonagy, P., 270 medication, 168
Foote, B., 110 mindfulness research, 164
Forman, Evan, xiii overview of treatments, 161
Freud, Sigmund, 1, 383 sleep hygiene research, 164
Friedman, A., 142 3P model, 160
functional communication training (FCT), ASD, useful resources, 168
312–313 youth approaches, 165
function-based behavioral management, cognitive loss, intellectual developmental disorder (IDD)
226–231 characteristics, 304
diagnostic criteria and symptoms, 304–305
Gallagher, M., 220 prevalence of severe IDD, 305
general psychiatric management (GPM), borderline per- See also autism spectrum disorder (ASD)
sonality disorder, 268 interpersonal psychotherapy (IPT), eating disorders, 143
Gentile, J. P., 114 interpersonal support, psychosis, 291
Ghosh, D., 113 interpersonal targets, depressive disorders, 19
Gitlin, L. N., 229 intimate partner violence (IPV), assessment of, 370
Goldfarb, E. S., 184 intrusive thoughts, as common experience in the general
Goldstein, L. H., 109 population, 66
Graham, C. A., 186
Gregori, E., 313 Jacobson, 366
Jacoby, R.J., 52
Hall, K. S. K., 186 Janet, P., 64
Hare Psychopathy Checklist, 247 Janoff-Bulman, R., 82
Hartley, M., 314 Jepsen, E. K., 113
Hayes, S. C., 221 Johnson, M. J., 370
Heijerman-Holtgrefe, A. P., 357 Johnson, V. E., 175
Heiman, J. R., 182
hoarding disorder, 68–69 Kabat-Zinn, J., 314
Hodgson, R.J., 65 Kalogeropoulos, D., 181
Hoeboer, C. M., 113 Kaminski, J. W., 255
Hollon, S. D., 70 Kaplan, H. S., 175
Holtzworth-Munroe, A., 370 Khalifa, N. R., 257
homeopathy, 6 Kiep, M., 314
homework, PTSD, 85–86 Klonsky, David, xiii
Horner, R. H., 306 Koenigsberg, H. W., 271
Hume, K., 306, 320 Kozak, M. J., 51, 67, 73
Huntjens, R. J. C., 111 Kurz, A., 223
Hupp, S., 6
Hussian, R. A., 220 Langeland, W., 105
Larouche, J., 181
Iadarola, S., 319 learning theory, ADHD, 332–333
inhibitory learning model (ILM), 71 Lewy body disease, 219
412 Index
Lieberman, L. D., 184 mutual support organizations (MSOs), SUDs, 196
Lilienfeld, S. O., xiii, 5 Myrick, A. C., 108
Linardon, J., 142
Linehan, M. M., 266, 270 narcissistic personality disorder, 271, 273
Linton, S. J., 123 Neely, L.C., 312
Lipsey, M. W., 251 Nepo, K., 311
Lovaas, O. I., 306 neuroticism, relationship with anxiety disorders, 47,
Lucchesi, K. E., 309 56–57
Lundahl, B., 199 nonsuicidal self-injury (NSSI), DBT as treatment for, 271
Lynch, 272 Novick, D. M., 30
Lynn, S. J., xiii, 110 Nuernberger, J. E., 309

Macfie, J., 111 obsessive-compulsive disorder (OCD), 64–75

MacNaul, H. L., 312 assessment and diagnosis, 72–73
Magill, M., 197 behavioral experiments, 71
major depressive disorder (MDD) categories, 64
definition and diagnostic criteria, 11 comorbidity, 73, 354
differentiating from borderline personality disorder, credible components of treatments, 70–72
41 cognitive therapy, 71–72
similarities with depressive episodes in bipolar dis- exposure, 70
order, 30 demographic considerations, 74
SUDs and, 204 etiology and theoretical underpinnings of treatment,
variability within, 21 65–66
Markman, H. J., 367 “inferential confusion” model, 66
Masi, G., 257 medication, 74
Masters, W. H., 175 overview of treatments, 67
May, B. K., 312 prevalence estimates, 64
McCart, M. R., 255 related disorders, 68–69
McCracken, L. M., 127, 129 research support, 69–70
McGuire, 250 treatment packages, 67–68
McKay, D., xiii, 70 useful resources, 75
McMain, S. F., 268 youth approaches, 72
Meana, M., 177–178 obsessive-compulsive personality disorder (OCPD),
measurement-based care, effectiveness in treatment of 271, 272
depressive disorders, 21 other specified feeding and eating disorder (OSFED),
Merikangas, K. R., 41 139, 140
Meyer, V., 67 overvalued ideation (OVI), OCD, 73
Miklowitz, D.J., 35
mindfulness pain
ADHD, 335 definition, 122
chronic pain, 128–129 See also chronic pain.
definition, 335 Patterson, G. R., 223
insomnia, 164 peer support programs, psychosis, 288–289
sexual dysfunction, 182 Perry, A., 33
SUDs, 198 persistent depressive disorder (PDD), 11, 21
tic disorders, 353 personality disorders (PD), 265–276
mindfulness-based cognitive therapy (MBCT), 18, 21, Alternative Model of Personality Disorders (AMPD),
314, 335 273, 274
mindfulness-based stress reduction (MBSR), 2, 129, 314 antisocial personality disorder, 272–273
mindfulness-based therapy (MBT), 314–315 assessment and diagnosis, 275
Mohajerin, L., 110 avoidant personality disorder, 272
Montgomery, G. H., xiii, 115 comorbidity, 275
Morin, J. F. G., 163 definition of personality disorder, 265
motivational techniques demographic considerations, 275
SUDs, 198–199 dependent personality disorder, 273
tic disorders, 351 etiology and theoretical underpinnings of treatment,
Mowrer, O. H., 83 266
 Index 413
medication, 275 psychoeducation
narcissistic personality disorder, 271, 273 bipolar disorder, 37, 40
obsessive-compulsive personality disorder (OCPD), depression and, 39
271, 272 eating disorders, 143–144
other PDs listed in DSM-5-TR, 273–275 psychosis, 289–290
paranoid personality disorder, 271 PTSD, 85
prevalence of various categories, 271 sexual dysfunction, 179
therapeutic approaches, 271 tic disorders, 352
therapies based on trait dimensions, 274 psychoeducational focus, in CBT-BP trials, 33
unspecified personality disorder, 272 psychosis, 282
useful resources, 276 assessment and diagnosis, 293–294
See also antisocial personality disorder (AsPD); bor- comorbidity, 294
derline personality disorder. credible components of treatment, 289–293
Peters, L., 199 care coordination, 292
phase-oriented treatment, dissociative disorders, emotion regulation, 290–291
107–108 interpersonal support, 291
Philipsen, A., 331 psychoeducation, 289–290
Pittenger, C., 65, 180 skills acquisition, 290
posttraumatic stress disorder (PTSD), 81 cure-focused approach vs. recovery model, 283
assessment and diagnosis, 89–90 demographic considerations, 294–295
comorbidity, 90–91 diathesis-stress model, 283
complex PTSD, 90 etiology and theoretical underpinnings of treatment,
credible components of treatments, 85–89 283
cognitive therapy, 88–89 importance of support and empathy, 289
exposure, 86–88 lifetime prevalence estimates, 282
homework, 85–86 medication, 284, 295
psychoeducation, 85 NICE guidelines, 285, 292
demographic considerations, 91 overview of treatments, 283, 284–289
DSM-5 criteria, 81 assertive community treatment, 285
EMDR controversy, 84 cognitive-behavioral therapy (CBTp), 284–285
etiology and theoretical underpinnings of treatment, family therapy, 286
82–83 peer support programs, 288–289
lifetime prevalence in the US, 81 supported employment interventions, 287–288
medication, 92 positive and negative symptoms, 282
overview of treatments, 83–85 psychosis spectrum disorders, 282
PTSD Checklist for DSM-5, 89 useful resources, 296
SUDs and, 204 youth approaches, 292–293
trauma types, 92 youth approaches, NICE guidelines, 293
useful resources, 93 See also schizophrenia.
youth approaches, 89 psychotherapy
Prick, A.E., 222 combining with pharmacotherapy, 23
problem-solving cultural considerations, 15–16
cognitive loss, 225–226 historical perspective, 1
core components, 17 psychedelic-assisted, 23
depressive disorders, 17 psychotherapy relationships, 381–394
tic disorders, 353 caveats and cautions, 391–393
Program for the Education and Enrichment of Relational definitions, 381–383
Skills (PEERS®), 315–316 evidence-based therapy relationships, 383–385
prompting, ASD, 311–312 recommendations for clinical practice and training, 393
Pseudoscience in Child and Adolescent Psychotherapy useful resources, 394
(Hupp), 6 what does not work, 390–391
Pseudoscience in Therapy (Hupp & Santa Maria), 6 what works
pseudoscience, use of in clinical psychology, xiii affirmation and validation, 387
pseudoscience-based therapy, 6 alliance, 385–386
psychedelic drugs, research on therapeutic congruence/genuineness and realism, 387
value, 23 emotional expression, 388
psychoanalysis, 1 empathy, 386
414 Index
psychotherapy relationships (cont.) symptoms, 282
feedback collection, 388–389 token economy programs, 287
goal consensus and collaboration, 386 useful resources, 296
overall, 389–390 youth approaches, 292–293
“Purple Hat Therapy,” 5 See also psychosis.
Putnam, F. W., 107 Schnicke, M., 82
Schopler, E., 306
Rachman, S., 65 science-based practice, definition, 5
Ramsay, J. R., 335 science-based therapy, the concept, 1–2, 5–6
“Rat Man” (Freud), 64 Seaman, R. L., 306, 319
Ratheesh, A., 40 Sesso, G., 257
Ray, L. A., 197 sexual dysfunctions, 175–188
Reichow, B., 306, 309 and comprehensive youth sex education, 184
relapse prevention assessment and diagnosis, 183–185
bipolar disorder, 39 comorbidity, 185
eating disorders, 148 credible components of treatments, 178–183
SUDs, 197–198 behavioral, situational, and contextual modifica-
tic disorders, 352 tions, 182
relaxation therapies cognitive restructuring/emotional regulation,
chronic pain, 128 179–180
insomnia, 163–165 mindfulness, 182
tic disorders, 351 psychoeducation, 179
reminiscence therapy, cognitive loss, 229 relationship skills-building, 183
Resick, P. A., 82, 88 stimulus control/desensitization, 181–182
Robertson, J. A., 162 cultural considerations, 186
Roddy, M. K., 365 demographic considerations, 185–186
Rogers, C. R., 383, 386, 394 etiology and theoretical underpinnings of treatment,
role playing, ASD, 310 176–177
Romano, M., 199 evasiveness of definition for outcome success, 178
Rosen, G. M., 5, 289 Masters and Johnson’s sex therapy approach, 175, 176
Rosen, N. O., 180 medication, 186
Rosen, R. C., 178 overview of treatments, 177–178
Rostain, A. L., 335 prevalence, 175
Roth, M. E., 307, 311 useful resources, 188
Rush, John, 34 Sidani, S., 163
Rybarczyk, B., 163 Simon, G. E., 36
Skeptical Inquirer: The Magazine for Science and
Safren, S. A., 330, 335 Reason, xiii
Salkovskis, 67 skills training
Santa Maria, C. L., 6 psychosis, 290
Schalock, R. L., 306 SUDs, 196, 198
schema therapy sleep interventions
borderline personality disorder, 269 cognitive loss, 227
dissociative disorders, 111 insomnia, 163
schizoaffective disorder, 282, 294 Smith, T., 319
schizophrenia Snyder, D. K., 365, 368
assessment and diagnosis, 293–294 social learning theory
comorbidity, 294 couple therapy and, 365
demographic considerations, 294–295 the concept, 365
economic burden in the US, 282 social skills interventions
importance of support and empathy, 289 ASD, 315–316
medication, 295 schizophrenia, 286–287
NICE guidelines, 285 social support
overview of treatments bipolar disorder, 40
cognitive remediation, 288 eating disorders, 146–147
cognitive-behavioral therapy (CBTp), 284–285 tic disorders, 350
social skills training (SST), 286–287 Society of Clinical Child and Adolescent Psychology, 3
 Index 415
Society of Clinical Psychology (SCP) Taylor, S., 73
role in conceptualizing and identifying ESTs, 2, 6 therapeutic alliance, 385–386
updated EST requirements, 3–4 therapeutic relationship
website, 3 role in treatment outcomes, 289
Socratic questioning value of, 14, 37
insomnia, 161 Thombs, Brett, xiii
psychosis, 284, 290 tic disorders, 344
PTSD, 82, 88 age of onset, typical, 344
Solanto, M. V., 330, 332, 335, 336, 337 assessment and diagnosis, 354
somatic symptom disorder, chronic pain and, 123 association with dysfunction in the basal ganglia, 74
Spain, D., 313 comorbidity, 354–355
Spielman, A. J., 160 credible components of treatments
Steffen, A. M., 231 awareness training, 348–349
Steinbrenner, J. R., 320 cognitive restructuring, 353
Steketee, G., 69 collaborative problem solving, 353
stigma, anxiety disorders and, 57 emotion regulation, 353
stimulus control interventions environmental modification, 350–351
cognitive loss, 226–228 mindfulness-based techniques, 353
insomnia, 162 motivational techniques, 351
sexual dysfunction, 181–182 psychoeducation, 352
substance use disorders (SUDs), 193 relapse prevention, 352
anxiety disorders and, 55 relaxation techniques, 351
assessment and diagnosis, 203–204 social support, 350
behavioral couples therapy, 197 strategies for mastery of skills and maintenance of
comorbidity, 204 treatment gains, 352
credible components of treatments tic suppression, 349–350
harm reduction, 201 demographic considerations, 355
motivational interviewing, 198–199 etiology and theoretical underpinnings of treatment,
nondrug alternative reinforcement, 199–201 345–346
skills training, 196–198 examples of, 344
definitions, 193 medication, 355–356
demographic considerations, 204–205 overview of treatments
etiology and theoretical underpinnings of treatment, comprehensive behavioral intervention for tics
193–195 (CBIT), 346–347
median age of onset, 41 exposure and response prevention (ERP), 347
medication, 205–206 habit reversal training (HRT), 346
mutual support organizations (MSOs), 196 prevalence estimates, 345
overview of treatments, 195 research support, 347–348
PTSD and, 204 treatment format, 357
screening tools, 203 useful resources, 358
useful resources, 206 youth approaches, 353
youth approaches, 201–202 token economies, 1, 287, 312, 351
suicidal behaviors Tolin criteria, xiii
recent increases among youth of diverse racial/ethnic and OCD research, 70
backgrounds, 21 and treatments for eating disorders, 142
SUDs and increased risk of, 204 and treatments for insomnia, 161
suicidal ideation and treatments for sexual dysfunction, 177
bipolar disorder and, 30 and treatments for SUDs, 195
DBT as treatment for, 271 CBT for ADHD and, 338
memory recovery treatment and, 112 empirically supported treatment status, 402
suicide feasibility of evaluating treatments with, 403
dissociative experiences associated with, 106 on the ingredients and mechanisms of therapy, 5
perfectionism tendency and risk of, 53 recommendation status of evaluated treatments,
suicide attempts, antisocial behavior and, 256 402
suicide rates, demographic considerations, 21, 275 treatment evaluation process, 402–403
systematic observations, cognitive loss, 226 updated EST requirements suggested by, 3–4, 401
systemic care, bipolar disorder, 36 Tourette’s disorder, 344
systems training for emotional predictability and transference-focused psychotherapy, borderline
problem-solving (STEPPS), 268 personality disorder, 269
416 Index
treatment evaluation Van Orden, K., 110
contextual factors, 403 Vargas, J. S., 307
feasibility, 403 Vedora, J., 312
librarians’ role, 403 video modeling, ASD, 309–310
the process, 402–403 Vlaeyen, J. W., 123
trichotillomania, 68–69 Vowles, K. E., 127, 129

Unified Protocol (UP) Walsh, 319

anxiety disorders, 48–49 Watts, B. V., 83
components, 48 Wilhelm, S., 69
dissociative disorders, 110 Wilson, D. B., 251
unspecified personality disorder, Wiseman, K. V., 310
272 Wolpe, Joseph, 1
Woods, D. W., 350
Van der Voort, T., 36
van Knippenberg, R. J. M., 226 Zimmerman, M., 271
van Minnen, A., 109 Zylowska, L., 335