Social Anxiety

Innovations and Advances in Cognitive Behavioural Therapy: Insights from Experimental Psychopathology - Editorial

Innovations and advances in cognitive behavioral therapy: Insights from experimental psychopathology

At its core, the goal of experimental psychopathology

is to understand what processes or mechanisms cause,

maintain, or otherwise contribute to mental health

problems (e.g., Zvolensky, Forsyth, & Johnson,

2013). There are countless examples of how this type

of research has led to important improvements in

treatment for people with psychological disorders.

Perhaps most famously, Beck’s (1963) findings that

people with depression consistently exhibit systema-

tic thinking errors (i.e., cognitive distortions) and con-

scious negative automatic thoughts revolutionized

how we help people with emotional disorders (see

Beck, 2019, for a history of cognitive therapy for

depression). Indeed, by spending a bit of time perus-

ing treatment recommendations by the National Insti-

tute for Health and Care Excellence (NICE), it

becomes clear quickly that cognitive behavioral

therapy (CBT) is now—and has been for a while—a

first-line evidence-based treatment for almost every

psychological disorder. As such, it would be easy to

conclude that “our work is done.”

However, many people continue to suffer with

mental health problems that either are not improved

following CBT or relapse following treatment; many

more are unable to access evidence-based care.

Understanding what mechanisms still need to be tar-

geted, for whom, under which conditions, and devel-

oping ways to increase access to these treatments is

vital. Experimental psychopathology comprises a

framework in which to make that happen. The goal

of this Special Collection was thus to bring together

experimental psychopathology research that contin-

ues to advance CBT for various psychological disor-

ders. Authors were invited to submit manuscripts

describing (1) original investigations of underlying

mechanisms of psychopathology, (2) original

investigations of new (or new variations of) CBT

interventions, or (3) reviews/integrations of a body

of published experimental psychopathology findings

that have led to recent innovations or have the poten-

tial to lead to innovations in CBT.

The result is an exciting special collection that runs

the gamut of mental health problems, experimental

psychopathology methods (experiments, case-study

designs, and randomized controlled trials [RCTs]),

includes both clinical and nonclinical participants,

and features reviews of experimental psychopathol-

ogy literature. Together, these articles suggest that

we have learned much, and that we have much to

learn about how to advance CBT and its accessibility

for people with mental health problems.

In their selective review, Gagné, Kelly-Turner, and

Radomsky (2018) focused on the science–practice

bridge (rather than the gap) to understand both how

research has informed the treatment of obsessive–

compulsive disorder (OCD) and how clinical experi-

ence can inspire experimental research. They pro-

vided a broad overview of etiological models of

OCD, with a particular focus on diverse cognitive

models such as the cognitive appraisal model and the

seeking proxies for internal states model. Through

examples of experiments across checking, obsessions,

contamination fear, and “just-right” symptom presen-

tations, they provided ideas for future research and

future practice. Indeed, throughout the years,

researchers have developed many clever studies that

shed light on the diverse cognitive mechanisms that

cause and maintain OCD (e.g., inducing thought–

action fusion by telling an experimental group that

if they think the word “apple,” a person in the next

room will receive a shock; Rassin, Merckelbach,

Muris, & Spaan, 1999) and thus provide potentially

fruitful treatment targets. There are also important

gaps in the experimental literature. Most notably,

“just-right” experiences have been largely understu-

died; clinical suggestions for treating this particular

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presentation are thus based primarily on theory.

Gagné et al. also suggested potential avenues for test-

ing some current clinical practices (e.g., responsibility

pie charts) to inform both theory and practice. Beha-

vioral experiments are a key theme throughout the

article; by developing individualized and collabora-

tive tests of beliefs with our clients, we may be best

able to target the key factors driving their symptoms.

Vidovic, Romano, and Moscovitch (2019) were

interested in understanding whether negative mental

images can be modified in an experimental study and

how this new technique might support therapeutic

gains. The authors introduced a brief version of ima-

gery rescripting—or changing the content of one’s

memory to meet the needs of one’s younger self—

as a technique to morph participants’ negative mental

images into ones that are more positive. Participants

were adults with social anxiety disorder and those

without any psychological diagnoses. They were ran-

domly assigned to receive either a short imagery

morphing session or a supportive counselling session.

Afterward, they completed daily homework assign-

ments and returned a week later for a speech task.

Although Vidovic et al. found that people (with and

without social anxiety) in the morphing condition

were able to use the technique effectively to morph

their negative imagery, there did not appear to be any

clinical benefit of this strategy. This was surprising,

given findings supporting more extensive imagery

rescripting as an efficacious technique among people

with social anxiety disorder. Although the research-

ers’ hypotheses were not fully supported, their find-

ings open the door for interesting and important

follow-up research questions, such as differentiating

between morphing an image and reappraising the

meaning of that image, incorporating theories and

findings from cognitive science (e.g., memory recon-

solidation), and establishing the optimal variations,

durations, and intensities of treatment techniques to

effect meaningful change. Here, we see a clever

example of how to use experimental psychopathology

methods to identify a novel technique and directly test

its efficacy for a particular type of presentation. The

refinement of this technique in subsequent research

has the potential to contribute to improved outcomes

for people with social anxiety disorder.

Ovanessian, Koerner, Antony, and Dugas (2019)

discuss the anxiolytic effects of different written

exposure tasks for people with generalized anxiety

disorder (GAD), with the goal of reducing the degree

to which people avoid their own anxiety-provoking

internal experiences. The authors astutely indicate

that, whereas imaginal exposures are used across all

CBT interventions for GAD, there is very little agree-

ment on the procedure under which clinicians and

clients plan and execute these exposures. By introdu-

cing imagery rescripting, Ovanessian et al. propose an

interesting mechanism with the potential to enhance

treatment for chronic worry. They randomly assigned

participants into one of three conditions (standard

written exposure, written exposure with rescripting,

and neutral writing control) and examined the scripts

as well as worry-related outcomes at baseline,

1-week, and 1-month follow-up. Although the authors

expected that people in the written exposure using

rescripting condition would experience the greatest

reductions in worry and GAD symptoms, the results

demonstrated that everyone—regardless of condi-

tion—experienced significant reductions in worry.

However, written exposure with rescripting did con-

tribute to improved cognitive outcomes, as partici-

pants in this condition rated their worst fear as less

costly and believed they could cope better than did

those who completed either the standard written expo-

sure or the neutral writing exercise. People in the

rescripting condition also demonstrated unique

improvements in GAD symptoms, fear of anger, and

fear of positive emotions. It seems that incorporating

rescripting in written exposures was not more bene-

ficial than typical written exposures, yet Ovanessian

et al. highlighted secondary worry-related processes

that warrant further exploration. The authors made a

novel contribution by directly comparing imagery

rescripting with typical written exposures in the treat-

ment of GAD. Their findings are important for CBT

for GAD as the rescripting condition—but not the

standard written exposure condition—experienced

different symptom improvements, which can help

clinicians collaborate with their clients to implement

one exposure technique over the other, depending on

how they have conceptualized the maintaining factors

for their symptoms and functioning. This is a direct

clinical contribution with important potential applied

outcomes.

Compared to many psychological disorders, eating

disorders are among the most fatal. To reduce the

relapse rates of individuals discharged from inpatient

services, Farrell et al. (2019) explored the effective-

ness of food-based exposures on individuals hospita-

lized with eating disorders, using a large case series

design. This contribution is particularly novel, given

that treatment in inpatient settings often prioritizes

2 Journal of Experimental Psychopathology

nutritional stability and avoidance of food-based

fears. The intervention consisted of gradually

approaching feared and avoided foods while ceasing

strategies aimed at reducing the individual’s weight or

changing their shape. As expected, patients experi-

enced significant reductions of food-related fears

from pre- to posttreatment. Not only were there no

increases (i.e., rebound effects) in self-induced vomit-

ing, compulsive exercising, or laxative misuse,

patients experienced decreases in self-induced vomit-

ing and compulsive exercising behaviors. Patients

also reported favorable perceptions of the treatment’s

helpfulness and consideration of emotional needs and

reported that they would recommend this treatment to

others. The authors’ findings suggest that food-based

exposure therapy in inpatient settings has positive

overall effects, and may generalize across eating dis-

order presentations, symptom severity, and food-

related fears and avoidance behaviors. These results

are exciting and encouraging for implementing this

type of intervention into current CBT practices, as the

authors suggest that time-limited behavioral interven-

tions contributed to important gains—rather than sim-

ply focusing on weight restoration. Furthermore, in

line with the cognitive behavioral model, this article

also highlights that targeting one component (i.e.,

behavior) can have many secondary positive effects

(i.e., cognitions and emotions). Indeed, this important

study provides yet another example of how applying

evidence-based theory to practice results in improve-

ments for patients and clients.

Kane et al. (2019) reviewed experimental research

focused on the effects of anxiety on sexual arousal to

better understand whether anxiety is helpful, unhelp-

ful, or has no influence on sexual arousal. The authors

set out to provide suggestions for developing and

refining current CBT interventions for sexual dys-

function. They emphasized a commonly shared view

of theoretical models that sexual dysfunction is heav-

ily influenced by beliefs and perceptions. Kane et al.

noticed that the literature held many contradictions

regarding the helpfulness (and unhelpfulness) of anxi-

ety in the context of sexual functioning. For example,

despite theory and initial research suggesting that

anxiety may play an excitatory role in sexual arousal,

the authors also observed the opposite when review-

ing more recent research, meaning people experi-

enced decreased sexual functioning (or no change in

sexual functioning) when researchers induced anxiety

experimentally. The authors also observed conflicting

evidence for the role of performance-based fears in

sexual arousal. Contrary to early theories wherein

researchers suggested that people with performance-

based fears would demonstrate inhibited sexual arou-

sal, the authors found evidence that people’s

performance-based fears, at times, had no effect on

sexual arousal, and at other times, increased sexual

arousal. Thus, they concluded that the interplay

between anxiety and sexual arousal is likely more

complex than once believed, and as such, theoretical

models require updates to reflect the various empiri-

cal findings. Kane et al. proposed exciting new ave-

nues for experimental psychopathology research,

including experimental studies that better incorporate

and manipulate people’s beliefs about sex and anxiety

(e.g., anxiety sensitivity) to advance our understand-

ing of the complex relation between anxiety and sex-

ual functioning. This detailed review highlighted how

far cognitive behavioral models of sexual functioning

have come, but also demonstrated large gaps in

knowledge that could be filled using experimental

psychopathology methods. Indeed, they ultimately

concluded that clinicians need to use caution imple-

menting anxiety-based interventions for sexual dys-

function, given the lack of clarity inherent in the

extant evidence.

Finally, McDermott and Dozois (2019) conducted

an RCT focused not only on treatment efficacy but

also on increasing access to evidence-based care, with

the goal of reducing the long-term burden of depres-

sion symptoms. They recruited a large sample of

undergraduate students with elevated self-reported

distress or neuroticism. Participants completed base-

line symptom measures and were randomly assigned

to complete 6 weeks of one of three online interven-

tions: (1) CBT (MoodGym; Christensen, 2004), (2)

Attentional Bias Modification, or (3) Attentional

Control Condition. At both post-intervention and

4-month follow-up, participants who completed

online CBT reported reduced depressive symptoms

and were less likely to report symptoms meeting diag-

nostic criteria for Major Depressive Disorder than

those in either of the other two conditions. In other

words, the online intervention appeared to reduce cur-

rent symptoms and potentially prevent the onset of a

depressive episode. Notably, over 100 participants per

condition remained in the study until 4-months post-

treatment, highlighting the great potential for

increased access to evidence-based services offered

by online interventions with minimal human

resources. A particularly important contribution of

this study is that McDermott and Dozois extended

Editorial 3

findings from past research by demonstrating that

online CBT may have a direct effect on reducing the

incidence of diagnoses, and that its effects can be

maintained over a longer-term interval.

In putting this Special Collection together, I took a

broad view of experimental psychopathology. Indeed,

there is an argument to be made that RCTs, for exam-

ple, are better understood as applied or clinical psy-

chopathology research rather than as experimental

psychopathology (e.g., Zvolensky, Lejuez, Stuart, &

Curtin, 2001). However, given the experimental

nature of much clinical research, and the overarching

goal of experimental psychopathology to determine

the causal and maintaining factors of psychological

disorders (thus providing direct treatment targets),

combining these frameworks may be the optimal way

to truly bridge the science–practice gap. Moreover,

differentiating between a full-blown RCT and a

well-controlled preliminary experiment testing a

potential technique (with the goal of testing a theory)

is complex, and perhaps not helpful. By focusing on

experiments that have the potential to lead to large-

scale advances in treatment, we have a much better

chance of helping people whose symptoms continue

to be impairing.

Although there may be an inherent assumption that

experimental psychopathology research necessarily

carries downstream clinical implications (Zvolensky

et al., 2001), its findings do not always translate to

improvements for people suffering from psychological

disorders. To be clear, understanding phenomenologi-

cal characteristics and correlates of psychological dis-

orders has much to add to the knowledge base;

however, focusing on mechanisms of change that

therapists can readily address in therapy is key to

reducing symptoms (e.g., see also Ouimet, Ashbaugh,

& Radomsky, 2019). The researchers who contributed

work to this Special Collection have truly taken that

idea to heart in developing and implementing their

studies.

Taken together, the series of studies in this Special

Collection highlight the important role played by

experimental psychopathology in developing, refin-

ing, and facilitating access to CBT for a wealth of

psychological disorders. The contributors to this col-

lection have shed light on past and current experimen-

tal research, applied it directly to potential therapeutic

techniques, and tested the efficacy of novel methods

for treating specific symptoms and disseminating

such treatments. They have also put the spotlight on

areas in which research is still lacking—and thus

people who are still not receiving optimal treatment.

It is particularly hopeful to see how experimental

psychopathology research can be readily translated

to treatment, suggesting that for people who are cur-

rently undertreated, advances are very likely

forthcoming.

Allison J. Ouimet (Guest Editor)

University of Ottawa, Canada

Ryan J. Ferguson

University of Ottawa, Canada

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Editorial 5